As Congress argues over whether to extend Affordable Care Act premium subsidies — a debate that could push millions into higher out‑of‑pocket costs if unresolved — economist Craig Garthwaite says the discussion should go beyond who pays and focus on how care is delivered. Garthwaite, director of the Program on Healthcare at Northwestern’s Kellogg School of Management and coauthor with Tim Layton of an Aspen Economic Strategy Group paper titled “Coverage Isn’t Care,” urges reforms that boost supply and improve efficiency so more people can actually access care.
Garthwaite points out that the subsidy fight mainly determines who covers the bills — the federal government or individuals — rather than addressing the underlying cost and value of healthcare. “All that’s going to change is who pays for it,” he says, arguing that attention should shift to total spending and whether patients receive high‑value care.
The paper lays out practical, supply‑side steps to expand the workforce and redirect resources toward low‑income communities where access is most limited. Two central proposals are:
– Easing limits on foreign‑trained physicians: The U.S. could increase clinician supply by allowing graduates of accredited international medical schools to practice here under programs that require them to serve primarily low‑income patients, including those on Medicaid. The goal is to relieve shortages in underserved areas, not to create a two‑tier system; for many low‑income people the immediate problem is simply getting any care.
– Expanding scope‑of‑practice for mid‑level providers: Nurse practitioners and physician assistants, who have advanced training, can deliver high‑quality primary care at lower cost. Allowing them to practice more independently would create more appointment capacity, give patients more provider time, and reserve higher‑cost physicians for more complex cases. Value‑based practices already rely on mid‑level clinicians, and the paper recommends extending similar models to Medicaid and other programs serving low‑income populations.
Acknowledging the difficulty of sweeping federal reform, Garthwaite highlights states as practical laboratories. Because Medicaid is state‑administered, agencies can use waivers and other flexibilities to pilot these ideas and scale up promising approaches without waiting for Congress.
The core argument is pragmatic: reducing the actual cost of care and removing supply barriers will allow the health system to serve more people more efficiently. If policymakers focus on delivery as well as payment, the nation can get more health for its dollars and improve access for low‑income Americans. The interview was conducted by NPR host Miles Parks.