Health maintenance begins before we are even born. For most of our lives, it does not consist of complicated interventions, surgeries, or expensive medications. Rather, from the early years through one’s mid-forties , health maintenance is almost entirely disease prevention. From the health care delivery end, it involves mainly monitoring and screening, vaccines, and counseling. We know that preventive care can help reduce disease burden in the population and, by doings so, could potentially reduce the overall costs of healthcare. Since we can anticipate everyone needing this very predictable care, and since we know it will benefit the community, it should be made easier to access. To truly enjoy the benefits of preventive healthcare in the population and maximize its effect, all preventive health services should be covered by a single public payer, not requiring formal enrollment.
Introduction of the Affordable Care Act (ACA) increased insurance coverage and made preventive services a requirement for health insurance companies. Enrollment in insurance programs increased, as did use of the health system. While this is an admirable shift, acquiring health insurance still remains a significant barrier for some subsets of the population. In 2020, some 30 million (11.1%) U.S. residents remained uninsured . Surveys show that the lower the family income, the more likely a family is to be uninsured.  those who remain uninsured report most commonly that affordability is still a concern for them . Still, the increase in utilization of preventive services by those who did get coverage , suggest that if patients know they are covered they may be more likely to seek preventive care. Making these services universally available would remove the hurdle of needing to acquire employment or independently enroll in a health care plan to access them – and perhaps get these services to the communities who may benefit from them most.
Unlike emergencies or acute illnesses, preventive services are predefined and theoretically given on a predictable schedule. Robust risk assessments are not required to understand their costs, which should be relatively low compared to the expenses associated with hospitalization. This would make it simple to budget for them reliably on an annual basis. Their predictability and guideline-directed frequencies also make the use of co-pays to limit overuse redundant. The ACA did remove cost sharing from preventive services in most circumstances, however there are some exceptions (e.g. receiving them from an out-of-network provider) . With this structure, every provider would essentially be an “in-network” provider for certain services. Additionally, having one payer for these services could increase bargaining power to further reduce their costs.
The notion of a true single-payer system continues to face substantial resistance and would be very difficult to achieve, both politically and logistically, in the near future. However, there may be more support for universally offering things like vaccines and screenings. Certainly, access to free covid tests over the last two years has been a boon, though the critical nature of the pandemic we are experiencing may have made openness to this a lower-hanging fruit. Yet, it may have set the stage for a culture more supportive of regular preventive care, especially if it is made convenient. Even before covid, there were systems to receive free flu vaccines without insurance, through work, the health department, schools, or state vouchers . Yet, this patchwork systems puts the onus on the patient to figure out where and if they are eligible for a free shot. Why not simplify this in such a way that certain services are simply free, if designated as preventive and take the extra steps out of the equation?
A complete single-payer health system may be a way off, but laying the groundwork for it by at least covering all preventive care could be a step in the right direction. Starting in this way could sidestep the national anxiety on the availability and distribution of complex care in late-stage disease in an entirely socialized system. It could instead focus on lower cost, standard services that everyone needs even at the very beginning of their lives. It may be easier to garner support for this program which provides at least one service to everyone every year, rather than rely on a “pay-it-forward” or altruistic mentality. Though I would hope that equity becomes a core value for all of us one day, the appeal to self-interest could help this intervention succeed. And, in the process of creating this system for free and universal delivery of preventive care services, we would be building and troubleshooting the foundation for a greater single-payer framework.
- Boersma P, Black LI, Ward BW. Prevalence of Multiple Chronic Conditions Among US Adults, 2018. Prev Chronic Dis 2020;17:200130. DOI: http://dx.doi.org/10.5888/pcd17.200130 https://www.cdc.gov/pcd/issues/2020/20_0130.htm#table
- Sommers BD, Gawande AA, Baicker K. Health Insurance Coverage and Health – What the Recent Evidence Tells Us. N Engl J Med. 2017 Aug 10;377(6):586-593. doi: 10.1056/NEJMsb1706645. Epub 2017 Jun 21. PMID: 28636831. http://medicine.tums.ac.ir/filegallery/2299016929/nezamoleslami%2031%20ordibehesht.pdf
- Finegold K, Commy A, Chu RC, Bosworth A, Sommers BD. Trends in the U.S. Uninsured Population 2010-2020. Issue Brief (ASPE) 11, Feb 2021. https://aspe.hhs.gov/sites/default/files/private/pdf/265041/trends-in-the-us-uninsured.pdf
- Collins SR, Gunja MZ, Doty MM, Beutel S. Who Are the Remaining Uninsured and Why Haven’t They Signed Up for Coverage? Issue Brief (Commonw Fund). 2016 Aug;24:1-20. PMID: 27538268. https://www.commonwealthfund.org/publications/issue-briefs/2019/aug/who-are-remaining-uninsured-and-why-do-they-lack-coverage?redirect_source=/publications/2019/aug/who-are-remaining-uninsured-and-why-do-they-lack-coverage
- Boston Public Health Commission. GET VACCINATED! Web. Accessed Feb 7, 2022. https://bphc.org/whatwedo/infectious-diseases/flu-information-center/Pages/Get-Vaccinated.aspx