Craig Garthwaite, director of the Program on Healthcare at Northwestern’s Kellogg School of Management and coauthor of a new Aspen Economic Strategy Group paper, argues the national conversation about Affordable Care Act subsidies is missing a larger point: subsidies mostly change who pays, not how much we spend or the value patients receive. In their paper, “Coverage Isn’t Care,” Garthwaite and coauthor Tim Layton propose a supply-side agenda to increase access and lower real health care costs—especially for low-income Americans.
Rather than focusing solely on premium support, the authors urge policymakers to expand the clinician supply in places where access is most constrained. One recommendation is to relax barriers for qualified foreign medical graduates through targeted programs that allow them to practice in the U.S. in exchange for commitments to serve low-income and Medicaid patients. The goal is to increase the number of providers willing and able to care for populations who often struggle to find appointments, not to lower standards of care. Garthwaite emphasizes that the problem for many patients is access, not inherently poor treatment: low-income people are already seen in different sites of care, and expanding providers who accept Medicaid can reduce unmet needs.
A second major proposal is to broaden independent practice authority for mid-level clinicians—nurse practitioners and physician assistants. These professionals have advanced training, frequently deliver high-quality primary care, and can do so at lower cost. They also tend to spend more time with patients and are commonly used in value-based care models. Allowing greater autonomy for NPs and PAs could quickly enlarge the primary care workforce and improve access for Medicaid enrollees and other underserved groups.
Garthwaite acknowledges these ideas are not entirely new: states already vary in residency requirements and scope-of-practice laws. His point is less about inventing novel tools than about better deploying existing ones and directing them toward measurable access gaps. Because Medicaid is administered by states, many of these reforms can be tested and scaled through state waivers and other mechanisms. Skeptical that Congress will pass sweeping changes, he endorses state-level experimentation: states can act as laboratories to discover which policies actually increase access and lower costs for low-income populations.
The broader objective is to reduce the true cost of delivering care so more people can receive needed services efficiently. If supply-side reforms succeed in lowering overall spending while maintaining or improving quality, the system could extend care to far more people without merely shifting who pays the bill.