Craig Garthwaite, director of the Program on Healthcare at Northwestern University’s Kellogg School of Management and coauthor of a new Aspen Economic Strategy Group paper, says the U.S. should look beyond insurance subsidies to reforms that increase care and lower costs.
As lawmakers squabble over extending Affordable Care Act subsidies—decisions that will affect millions’ premiums—Garthwaite warns that the debate too often treats subsidies as if they change how much the country spends on health care. “All that’s going to change is who pays for it,” he says. The more important questions, he argues, are how much we spend on health care overall and what value patients receive for that spending.
His paper, titled “Coverage Isn’t Care,” offers a supply-side roadmap to improve access and efficiency, particularly for low-income Americans. One recommendation: ease restrictions on physicians trained abroad by creating programs that let qualified foreign medical graduates practice in the U.S. in exchange for concentrating on low-income and Medicaid patients. The idea is to expand the supply of clinicians who will treat populations that currently struggle to find care.
Garthwaite stresses this wouldn’t necessarily provide lower-quality care for poorer patients; the U.S. already has different sites of care where low-income people are treated, and often the pressing issue is access rather than quality. Expanding the workforce focused on Medicaid patients could reduce instances where people simply cannot find a provider.
Another major proposal is broadening the independent practice authority of mid-level providers—nurse practitioners and physician assistants. These clinicians have advanced training and can deliver high-quality primary care at lower cost. They often spend more time with patients and are widely used in practices focused on value-based care. Allowing them to practice more independently could quickly augment the primary care workforce and improve access for Medicaid and other low-income populations.
Garthwaite acknowledges that these changes aren’t entirely novel; states already vary in residency requirements and scope-of-practice laws. Rather than inventing new tools, he suggests better deploying existing ones and targeting them at populations with clear access gaps. Many of the reforms he and coauthor Tim Layton propose can be implemented at the state level. Because Medicaid is administered by states, agencies can use waivers and other mechanisms to test and scale policies that expand provider supply or change practice rules.
While skeptical about Congress’s ability to pass major reforms, Garthwaite welcomes state experimentation. “States can be the laboratories of democracy,” he says, acting as laboratories for low-income coverage to discover what actually increases access to care.
Ultimately, the goal is to lower the real cost of health care so more people can receive needed services efficiently. If supply-side reforms reduce overall spending, the system could deliver care to far more people without simply shifting who foots the bill.