The Star Tribune Editorial Board laid down a challenge for health care in “Find middle-ground on ‘Medicare for All’ ” (Aug. 24). It argued for practical steps to improve health insurance, avoiding all-or-nothing options.

I agree. The reality for many of us is that getting health insurance — whether you buy it on your own, get it through work or get it through a public buy-in — is an empty victory when we can’t afford the premiums, deductibles, drug copays and other medical bills not paid by insurance.

Today’s problem isn’t getting care; today’s problem is paying for it.

Thanks to the Affordable Care Act, we can get insurance whether we’re sick or healthy, young or old. That’s a big deal. But it isn’t enough. As the head of the Minnesota Council of Health Plans, I spend my time figuring out what makes health care a budget-buster for households, businesses and government. The high premiums paid by people who buy their own insurance are just the most visible sign of the deeper trouble. Health insurance is expensive because health care is expensive. We think up new forms of insurance but avoid public policy discussions that really address the root causes of high medical bills.

The all-or-nothing ideas voters are hearing make it too easy to put off critical conversations, including two issues facing Minnesota policymakers next year. These decisions will determine whether we stay steady or backslide in helping more than 344,000 Minnesotans pay for care.

About 25 years ago, Minnesota put in place a simple way to help more people get care upfront and prevent extremely expensive bills later. Known as the provider tax, it helped fund original MinnesotaCare and today helps nearly 182,000 Minnesotans who earn less than $16,800 a year pay for care through Medicaid. If policymakers allow the provider tax to expire next year as planned, we’ll have a $700 million hole in the state budget, hurting people in every county across the state.

Thanks to state legislators, another 162,000 Minnesotans, those who buy insurance on their own, get help from reinsurance. Reinsurance, which pays part of high medical bills so those expenses aren’t added to people’s premiums, ends soon. This year reinsurance meant that most people across the state had at least two options for buying health insurance, for 15 percent less on average. Early 2019 numbers from the Minnesota Department of Commerce show premiums going down even more. The federal government gave Minnesota permission to operate this program for three more years. Policymakers need to act quickly next year to use leftover funds to keep helping these Minnesotans.

I know these two practical ideas treat symptoms rather than directly addressing the underlying problem of the high price of health care. The provider tax and reinsurance work. But they are not enough.

Individuals alone can’t do much to address high medical bills because the prices we see don’t mean much. Public policy help is needed. We know from studies by Minnesota Community Measurement and the Minnesota Department of Health that the bill depends entirely on where you go for treatment, and the price paid depends on who is paying the bill. According to data from the Minnesota Hospital Association, the gap between what local hospitals were paid by Medicare and Medicaid, and what they would have been paid by private insurance for the same care, grew by $1 billion between 2012 and 2016. It’s a problem that continues to get bigger.

I’ve worked on this issue for a long time, first from the state budget side and now with private insurance. I’m optimistic that we can build on the successes we’ve had. The issues we face today aren’t that different from those that brought us the MinnesotaCare reforms 25 years ago.

Back then, the problem facing the whole state was that people couldn’t get care. Today’s problem is we can’t afford it. Now, as then, we need to have real conversations that acknowledge the tradeoffs in various proposals. In the end, we need practical actions that work for all Minnesotans in communities across our state.

Jim Schowalter is president of the Minnesota Council of Health Plans.