We are at a watershed moment for health care, both nationally and in Massachusetts.

Massachusetts, the state that first piloted the model, “Romneycare” in 2006, that was disseminated to the nation as “Obamacare” is now going full steam ahead with ACO models under the newly approved 1115 waiver, that received the CMS green light in early November. Having expanded to near universal coverage in 2006, now, at the end of 2016, we are taking on the challenge of payment reform at scale, while also addressing population and community health. In particular, there is an opportunity to address “social determinants of health” as a valid part of medical care in the MassHealth ACO models.

Meanwhile, on the national stage, there is a promise to dismantle not just the Affordable Care Act (Obamacare) but to restructure all of the federal government in a way that dramatically reduces the safety net. The mantra is small government and personal responsibility.

The debate often gets heated. The details of policy solutions get complicated. Below are 10 questions to consider to broadly frame the issues:

1. Health care: Is it a right or a privilege? Are there certain categories of people who have a right? (e.g. children, pregnant women, disabled) What makes someone “deserving”? Are there certain services that should be always covered (e.g., life-threatening)? How do we define the categories?

2. What does it mean to be uninsured versus underinsured? At a time of rising healthcare costs, increasing cost-sharing/shifting to consumers, narrowing networks, what does it mean to have “adequate” insurance?

3. Minimum coverage requirements: Should they be broad or narrow? Should young or healthy people be allowed to carry only catastrophic coverage? Is one annual preventative health visit sufficient for those who are healthy or should prevention be defined more broadly? What care is considered “extra” and should be a personal expense? Should people have affordable access to “designer drugs” or experimental treatments?

4. Personal responsibility: Is that driven by financial penalties/incentives or does it come from improving a culture of health? Does cost-sharing, or “skin in the game” cause people to forego needed care or avoid unnecessary care? Do people make logical and sound decisions about health? Is it our business if people do not make wise decisions and end up in poor health or with unaffordable bills?

5. Informed choice and transparency. In context of low health literacy and numeracy and with complexity of system, is there genuine informed choice? Is transparency sufficient to offer consumer protections or does there need to be greater regulation? Is health too emotional and anxiety-provoking a topic to be akin to selecting a cell phone plan?

6. Data and analysis. What are the right measures of success and in what time frame? Should there be broad measures that include quality of life and functionality or more narrow measures that map to services delivered? Should there be long-term or a short-term evaluation? What is the right timeframe to assess for good outcomes versus harm? How does one measure pediatric health and outcomes?

7.What operational model drives quality and efficiency? Does increased competition promote better quality or does it only fragment the system? Does offering contractors and vendors a profit incentive to provide better care drive efficiency or does it only add cost? What is the right oversight mechanism of vendors who may not be governed by the same public sector transparency rules?

8. Is health care a business, a science, an art, or a sacred calling? Should profit be allowed and are there limits to profit? Is there a social contract involved in healthcare delivery and services or should a good idea or market opportunity be able to be maximized for profit? How much variation of care should be allowed?  How much self-sacrifice is expected of those who provide care? Do those in service professions have a right to career satisfaction?

9. Patient-centered versus consumer-driven. Is the basis of healthcare a sacred therapeutic relationship or about humanistic relationship-based care or is it a business transaction of services delivered to consumers who compare options and chose the best? How does one measure or think about satisfaction while following evidence-based medicine. What prevails when there may be some things a patient wants that may not be in their best interests (e.g. antibiotics for a viral illness)? How much of the experience of care matters?

10. Economic aspects of acute medical care versus population health? To what extent does the healthcare system need to address about health of all Americans? Is the economics of healthcare about reducing costs and improving outcomes as related to the healthcare system like HEDIS measures? Or should be more emphasis on improving measures tracked by the CDC? What is the impact population health on our economy (e.g. disease burden, loss of work and function, productivity)?

Umbereen S. Nehal is a pediatrician and a health services research fellow.

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