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Trending: Revolution or Reform? How the Health System Is Changing

By Ron Pollack,


Each month, we weigh in on selected news stories and trending debates that are shaping the direction of health care policy.

The start of the second open enrollment period is less than 50 days away. Like many of you, I’ve been finding myself increasingly caught up in the whirlwind of activity around preparations for the new enrollment season—ensuring that America’s working families have the information and resources they need to get covered and stay covered.

But, the other day, I came across an interview from 2010 that made me take a much-needed step back—and a commensurate look forward to the future of health reform.

The interview, which took place between Thomas Zeltner (former Swiss Secretary of Health) and Tsung-Mei Cheng (the host and editor of Princeton University’s International Forum and, incidentally, married to my friend Uwe Reinhardt), focused on what lessons Zeltner’s experience with the Swiss health system holds for the United States.

It’s a fantastic interview (you can read it here). But for me, the best part came at the end of their talk, when Cheng asks Zeltner what advice he would give U.S. policymakers based on his long experience:

“The . . . point I think we all have to learn is that it’s [reform] not done with a one-step reform. I think the reforms of our health care systems will be going on for the next decades or more. You end one reform and you start the next one. It’s a never-ending task.”

Zeltner then goes on to use the familiar and very apt analogy that reforming the health care system is “like fixing an airplane that is in the air.” Because of this, changes must be incremental, explains Zeltner:

“That’s the reason why I believe you have to advance very carefully, step by step. You can’t make a revolution in the health care system, because a revolution would, at least for a couple of months or years, block a system expected to function 24 hours a day and 365 days a year…

Two parallel processes need to be handled: working on a national consensus about the long-term perspective, and implementing measures along the way.”

My own take on reform is that, with the Affordable Care Act, we have indeed created change that could almost be considered revolutionary – and, despite significant problems, the plane is still flying:

  • We have laid the foundation for reducing the number of uninsured from more than 1 out of 7 people to something likely to approach 1 out of 15.
  • We have constructed a health coverage system that very substantially builds on an individual private health market system and on public programs, combined with tax credit premium subsidies for moderate-income families—which make health coverage much more means-sensitive and progressive.
  • The health insurance system is much more regulated than before—to the benefit of those who are most in need of health care.
  • And we have initiated the first rudimentary steps for a higher-quality, more value-based health system.

One of the most remarkable things about these changes –which may not be revolutionary but certainly come close to being so, and definitely are the most significant health changes over almost half a century –is that the changes occurred in the context of a nation that is probably more ideologically and politically divided than any of us can remember.

It is clear, therefore, why so much of our focus recently has been on grounding and protecting these enormous gains.

We are not yet out of this protective mode. However, we also need to look forward. The major changes envisioned by the health care law lay a critical foundation. But, as Zeltner posits, we need to think through and set in motion the next incremental steps so we move closer to a fair, value-based health system that ultimately gives everyone the peace of mind that they will be able to get the health care they need when they need it.

In the coming months, my colleagues and I will be focused on describing what steps the nation should take next to achieve these goals. I look forward to sharing our thoughts with you at the end of the year.