Health Care Reform: What Now? (2024)

On March 23, 2010, after two-years of bitter partisan debate, media hysteria over death panels, blatant politic arm-twisting, and special cloakroom deals (e.g. Cornhusker Kick Back, Louisiana Purchase), President Obama signed the Patient Protection and Affordable Care Act (ACA) into law. To put this current effort in proper perspective, its best to think of the ACA as yet another chapter in our long history of efforts to develop a more equitable health care delivery system. It is neither the end of the road nor the ultimate answer to health care reform

Health care reform has been on the public and political agendas since the early 1900s. Every President from Woodrow Wilson on has wrestled to some extent with health care issues. President Eisenhower used the tax code to encourage employer-based health insurance; President Johnson guided Medicare and Medicaid through Congress and into law; President Nixon fostered the development of managed care and the HMO model and President Bush ushered in prescription drug coverage for Medicare patients. Presidents, Harry Truman and Bill Clinton, attempted to pass a comprehensive national health insurance program but neither succeeded. Incremental changes aside, none of these prior efforts, either individually or collectively, have achieved the broad improvements in both access and cost containment that are critical to a sustainable health care system.

Today, the rising cost of health care in an economy that is slowly recovering from one of the deepest recessions since the 1930s has led to intense anxiety for many Americans. Just as the post-World War II “baby boomers” are approaching retirement, the financial stability of our Social Security and Medicare safety net are in serious financial jeopardy unless significant changes are made in these programs. A growing number of families are deeply worried about their future and their ability to afford health care when they need it most. Health care reform remains a critical issue and a fundamental prerequisite to getting our economic house in order. The longer health care reform lingers, the more precarious our system becomes and the more expensive it is to fix.

In our search for solutions, many have looked to our economic partners in the developed world for potential options. Germany, France, Britain, and Canada all provide their citizens with universal health care and do so at per capita costs much below that in the U.S. yet with outcomes that are, in general, better than ours. Germany and France fund their health care systems through “sickness funds” subsidized by combined patient and employer contributions. On the other hand, Britain and Canada provide universal care in a thoroughly nationalized (cradle–to-grave) government system. But, no matter how they are funded, the common variable for all of these alternatives is strong central (governmental) control of available services and their costs. There are at present no models which successfully provide universal health care and cost containment in a totally free market system.

However, the “European” alternative resonates poorly in this country. Despite the fact that our current system includes several government run health care programs, Americans have a basic distrust in the government’s ability to manage their health care. Our national culture is deeply rooted in the republican concepts of individual liberty, personal autonomy and freedom of choice. Those beliefs extend to health care in the sanctity of the physician-patient relationship, respect for personal values and freedom of choice that reflect the best interests of the patient. Any reform that socializes health care and eliminates the element of personal choice whether in the public or private sector is certain to quickly inflame the passions of both patients and their physicians.¹

Social safety net programs (i.e. Social Security, Medicare) and individual health insurance (private or public) have long been characterized as a political third rail. No matter how well intended, any attempt at “reform” has always been a highly emotional and politically-charged process. This latest effort was no exception. Despite the fact that the vast majority of Americans, including those in the health professions, firmly believe that universal access to health care should be a basic right for all citizens, public support for the ACA was sharply divided. During the legislative debates, Senators and Representatives were barraged with complaints about the bill by their constituents. Several recess town hall meetings degenerated into passionate if not vindictive tirades. Taken together, these sessions turned out to be prescient of what was to come. In the August 2010 primary election, following passage of the ACA, voters in Missouri overwhelming approved (71% for, 29% against) Proposition C instructing its legislature to ignore the individual insurance mandate in the ACA. Then in the November 2010 mid-term elections, voters returned the House of Representatives to Republican control and virtually eliminated the Democrats party-line super majority in the Senate in what the President humbly referred to as a “shellacking.” Outside the political arena, public opinion polls consistently found confidence in the Congressional and Administration leadership at new lows.

Besides voter protests, state governments registered concerns of their own. Many state governors, some among the newly elected Republicans, registered serious concern over the impact of Medicaid expansion for the uninsured on their future state budgets. Medicaid already accounted for the single largest expense in their budgets. Generally required to operate with balanced budgets, most of these states had been cutting back on Medicaid eligibility and enrollment to reach their budget mandates. Further expansion of that program could jeopardize their ability to provide other needed services to their constituents without major increases in state taxes, an unpalatable option for almost any legislator.

In addition to or as a result of their concerns about Medicaid, 26 states have either filed or joined lawsuits challenging the Federal Government’s authority to mandate individual health insurance under the Constitution’s “commerce” and “necessity” clauses. The outcome of those that have come to decision is mixed. Virginia’s recent appeal for expedited Supreme Court hearing was denied ensuring that the remaining challenges will continue to wind through the legal system. Legal pundits have suggested that an ultimate Supreme Court hearing and ruling would probably not occur before the fall of 2012 – coincident with the next general election.

What Now?

So, what happens now? The ACA is a matter of law and as such will continue as designed unless changes occur. That’s not to say all is settled. Many of its provisions will be implemented over the next four to six years. How those provisions roll-out and whether funding for them will actually occur as planned may well depend upon how the political winds blow.² So long as our economy remains mired in a sluggish recovery, there will be some serious jousting over Federal appropriations and tax law. There do not appear to be any guarantees as to how things will evolve. The current law (all 2,700 pages) gives us a “genotype” for ACA, but the “phenotype” remains, to some extent, unknown.

One of the first principles of reform is to know what is broken, what needs to be fixed, and in what priority those fixes should occur. Expanding health insurance to a larger segment of the population does not necessarily expand health care unless there are sufficient resources to do so. It can be argued, on fairly good evidence, that there are not enough physicians, specifically primary care physicians, to provide care for the newly insured. For over a decade now the trend in medicine has been away from primary care specialties (e.g. Family Practice, Pediatrics, General Internal Medicine) and toward specialties or sub-specialties. In the 1960’s, 70% of physicians listed in the AMA Master File self-identified their practices as primary care; 30% as specialty care. By the turn of the century this ratio had essentially reversed. Not only are there important disparities in the workforce, their geographic distribution is also uneven. Along with the trends toward specialization, physicians tend to accumulate in urban settings and increasingly in more corporate style business models (e.g. academic centers, multispecialty practices, hospital employed). Not only are there fewer primary care physicians, there are fewer physicians practicing non-urban rural settings. Hence there is a reasonable argument that says the ACA focused on the wrong problem. Expanding the number of insured patients in the absence of sufficient primary care physicians will either negate the benefits of insurance or drive more patients to Emergency Rooms for episodic care in one of the most expensive settings.

Issues of workforce mix aside, there are elements in the ACA which Organized Medicine can and should get behind. Insurance reforms such as guaranteed issue, prohibiting pre-existing conditions as a disqualifier for insurance, retaining older children on parental health insurance, prohibiting lifetime limits on coverage, and cancelation of policies for those with expensive disorders and requirements for premium dollars actually spent on health care are all issues that benefit our patients and practices. Making sure that all patients who are currently eligible for Medicaid and/or State Child Health Insurance Plans (SCHIP) are enrolled will certainly help lower the public’s uncompensated care burden. The adoption of hardware and software to implement an electronic health record (EHR) and e-prescribing will help improve the efficiency of care, reduce errors in treatment and, through Health Information Exchanges (HIE), improve integration of health care. Comparative Effective Research, if done with rigorous scientific methods, can help us sort through the myriad drugs and technological innovations to determine which are most beneficial to the patient we are caring for. Finally, participation in quality improvement/ reporting programs and the shift in reimbursem*nt from pay-for-volume to pay-for-quality will improve the care our patients receive.

In its final form, the ACA focuses primarily on expanding health insurance coverage and has only weak and somewhat disjointed efforts at cost control. The proposed “savings” that the ACA hopes to achieve will come largely from a group of programs (Accountable Care Organizations, Shared Savings Programs, Medical Home Models) designed to reform reimbursem*nt models that incentivize quality care. Many of these programs have not been extensively tested and any projection of “savings” remains somewhat speculative. Successful efforts will most likely be in large urban centers that already have a broad array of medical/surgical specialists and will be capable of forming partnerships between multiple practices and an established full-service hospital. ACOs will require access to substantial start-up capital and an ongoing volume of patients to sustain viability and realize cost savings. The Center for Medicare and Medicaid Services (CMS) readily admits that for an ACO to be effective under the Shared Savings Program would require enrollment of at least 5,000 Medicare patients. Furthermore, CMS does not anticipate receiving more than 75–100 applications for ACO status. Hardly a broad “cost-bending” exercise.

Finally, although legal experts disagree on the merits of the legal challenges to the individual insurance mandate, these do represent a collective “Damocles Sword” over the most fundamental feature of the ACA. If the mandate alone is ruled unconstitutional, only those uninsured who most need health care will likely enroll in a health insurance plan. They will in all probability be the sickest and most expensive to care for. Furthermore, the individual penalties for failure to acquire insurance are not sufficient to offset the premium loss that these healthier individuals would contribute to the insurance pool. Nor are they sufficiently high to persuade individuals to enroll short of an immediate or near-term need. It seems that whatever the resolution is, the future of the ACA may well be in the hands of the courts.

So, at best, the ACA is an unfinished product. Of necessity, there are bound to be significant changes to it down the road. The nature of those changes will likely be based on the ongoing results of expanded health care and the political winds, particularly if those winds are from the conservative direction. There is still much to do. Organized Medicine must remain vigilant both at home (locally) and nationally.

The Road Ahead

There are a number of important drivers of health care costs that the ACA does not address or does so inadequately. High on this list are fixing/repealing the flawed Medicare reimbursem*nt process (SGR) and putting Medicare on a sustainable course for future generations; meaningful reform of the medical liability system (tort reform) that reduces the costs for defensive medicine and meritless lawsuits; and improving access to preventive and primary care services to list a few key items. As I move through my year as your MSMA President, I will touch on each of these and others through Missouri Medicine and my travels within the state.

Let me conclude this initial conversation by inviting each of you to join me in what I believe are the most important objectives for the next year as well as the long-term future.

• Fundamental Medicare Reform, including the repeal of the SGR and the assurance of a sustainable program for future generations.

• Affordable, equitable, universal coverage for all Americans through market reforms

• Choice of health insurance plans available through a market place (exchange) that includes:

  • -Guaranteed Issue.

  • -No denials for pre-existing conditions.

  • -Individual responsibility for coverage and wellness.

  • -Premium assistance for those who need it.

• Medical liability reforms that address excessive cost of defensive medicine and the unnecessary cost of meritless law suits.

• Initiative to address the physician workforce:

  • -Strengthening MSMA ties with our colleagues in academic medicine

  • -Increasing the primary care physician workforce.

  • -Improving funding/reimbursem*nt for preventive and primary care.

  • -Student debt abatement programs linked to service in underserved primary care areas.

• Initiatives to improve the quality of care:

  • -Electronic health records.

  • -E-Prescribing.

  • -Integration of health care services.

• Preventive and wellness programs to keep our citizens healthy.

• Assist our patients in designing meaningful end-of-life care that reflects their values and expectations.

I look forward to serving MSMA and Missouri’s physicians over the next year.

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