With debate intensifying over whether to extend Affordable Care Act premium subsidies — a fight that could leave millions facing higher premiums if unresolved — economist Craig Garthwaite says the U.S. should broaden the conversation beyond who pays to how care is delivered. Garthwaite, director of the Program on Healthcare at Northwestern University’s Kellogg School of Management and coauthor with Tim Layton of a new Aspen Economic Strategy Group paper titled “Coverage Isn’t Care,” argues for structural reforms that increase supply and improve efficiency so more people can actually receive care.
Garthwaite notes that the current congressional dispute over subsidies largely affects who picks up the bill — the federal government or individuals — not the underlying cost of healthcare. “All that’s going to change is who pays for it,” he says, and that misses the more important questions of total spending and the value of care received.
The paper outlines practical steps aimed at expanding the workforce and redirecting resources to serve low-income populations better. Key proposals include:
– Easing restrictions on foreign-trained physicians: The U.S. could expand the supply of clinicians by allowing graduates of reputable international medical schools to practice here under programs that require them to focus primarily on low-income patients, especially those on Medicaid. The intent is to increase access where shortages are most acute rather than create a two-tiered system; Garthwaite emphasizes that the bigger issue for many low-income Americans is lack of access at all.
– Expanding scope-of-practice for mid-level providers: Nurse practitioners and physician assistants have advanced training and can deliver high-quality primary care at lower cost. Allowing these clinicians to practice independently in more settings could increase available appointments, offer patients more time with providers, and reduce reliance on higher-cost physicians for routine care. Practices following value-based care models already make extensive use of mid-level providers, and the paper recommends extending this approach to Medicaid and other low-income populations.
Garthwaite acknowledges political skepticism about large federal reforms, saying Congress often struggles to pass meaningful laws. But he points to states as practical laboratories for change. Because Medicaid is administered at the state level, state agencies can use waivers and other flexibilities to pilot many of the paper’s recommendations. These state-led experiments could identify effective models for widening access and reducing costs without waiting for sweeping federal action.
The overarching argument is pragmatic: lowering the actual cost of healthcare — not just shifting payment sources — would enable the system to provide care to more people more efficiently. If supply-side barriers are addressed, Garthwaite says, the nation can get more health for the dollars spent and improve access for low-income Americans.
The interview with Garthwaite was conducted by NPR host Miles Parks.
