2010–2020

Subsequent battles over the health care system moved to the states. Some states, like Vermont, launched single-payer systems. Some, like Maryland, used capitation and government regulation to encourage prevention, care integration, and other aims of the ACA. Others, like Kansas, obtained waivers in order to privatize their Medicaid programs. Over the years following 2012, the states seeking market solutions emphasized individual responsibility to keep costs down and demand quality. States using capitation increased access and drove providers and patients into integrated systems.

Confused by the different state policies, many employers opted for Consumer Directed Health Plans, offering their employees catastrophic insurance alone. However, large employers moved their employees into integrated delivery systems as a competitive edge for attracting and recruiting new and top talent. As a result, even without the ACA in place, the growth of integrated care systems with capitated payments continued, even in states that did not favor capitation plans.

At the national level, Republicans continued to oppose an increased government role in the health care system, while Democrats continued to run on a platform of expanded Medicare and Medicaid programs funded by higher taxes on the wealthiest Americans. The elections of 2012 and 2016 were hard-fought but inconclusive as a divided public produced a divided government in which Congress, administrations, and the courts continued to contest policy directions.

By 2020, studies clearly showed the trade-offs between states that relied on market solutions and those that actively regulated health care insurance to increase access, integrated systems, and support prevention. In states favoring integration costs had risen as the population grew. States that relied on markets also faced higher costs from faster growth in illness rates where prevention efforts stalled. In effect, neither the market nor the government regulation could effectively meet the need to constrain cost, provide a quality experience for patients, and improve population health.

The 2020 campaign slogans, most prominently “It’s our health, stupid!”, revealed a growing realization that it was health – more than health care – that needed national attention. After almost a decade of rigorous comparative effectiveness research using electronic medical records, the 2020 election set the stage for priorities and reforms that placed a greater emphasis on integrated health systems and on the non-medical factors affecting the health of the population.