Like petulant children in the backseat, we keep asking the familiar interrogatory question from the family vacations of our youth, but now it is about health care reform. Admittedly the changes were sold to us as a wonderful trip to a better place for the nation and for every individual. It has not helped that we have had a serious misstep of a detour right as we began the trip with the failure of healthcare.gov to deliver the promise of buying insurance with the same ease with which we purchase lace-ups from Zappos. This was sort of the vacation equivalent of running over the family cocker spaniel while leaving for the summer excursion to the lake. But before we give up entirely on this trip, we should ask and understand some basic questions.
How big a trip is this anyway?
It has not helped that we haven’t always been very clear about what was changing. Health care in the US is the sixth largest economic undertaking on the face of the globe – somewhere in between the British and Italian economy. To change it at its foundation – which is what this reform is about – is a big, complex, and lengthy process, at least a decade and a half in my opinion. We should anticipate missteps, because if we could do it perfectly, then we would not be doing a significant enough job to make a difference on the overall unsustainable cost of care and the extremely uneven quality of the outcomes that we produce. This is not an assembly project of a detailed blueprint of a carefully engineered plan that has been proven. That would be complicated enough. Instead, it is an invention project guided by some general values and directions that are encoded in the legislation and demanded by the market. As such it is an undertaking in complexity in which we will not know what problems to solve until the parts start to interact and shape the questions that need to be addressed. So lets not be naïve about the complexity, let’s embrace it. And understand that it will not all come together quickly.
Are there some general directions we should understand?
By all means, the law contains some values and general guidance about the new system that will emerge. The first principle is accountability. As we approach universal health insurance coverage it will mean that some organizations will bear the financial risk for expensive approaches to health that do not work. To be accountable and more responsive to consumers’ desires and needs, health care will need to be more integrated. Some of this will be virtual integration and probably more of it will be organizational and financial. There is also a clear assumption that the nation needs to rebalance the division of investment in the four big things that the provision of health entails: prevention, diagnosis, treatment, and management. With more attention being given to the first and last of these four. This in turn means more emphasis on, and perhaps some redefinition of, primary care. Finally, the changes are, in many ways, predicated on a different role for the consumer of health care as they become more engaged, more responsible, and better informed. One dimension of this new consumer awareness will be a better informed segment of the health care consumer market.
Have we passed any tollbooths?
The decision by the Supreme Court that left most of the legislation intact, by only giving states the option to opt out of Medicaid, was a major success and generally silenced the efforts at legal dissent at the state level. Obviously correcting many of the shortcomings of online enrollments and the impressive final numbers are also a sign of success. In early May 2014, an estimated 8.14 million people were enrolled in the exchange. Of those, 7.3 million seem to have paid some portion of a premium. In addition, Medicaid enrollment has increased by an estimated 4.8 million people as a by-product of the ACA. This entire enrollment does not represent individuals or families that did not have coverage last year, but most estimates are that a significant majority are the newly covered.
What is ahead?
There are five dimensions of the reform that I am looking forward to that we haven’t quite arrived at yet. First is the opportunity to do great things with the data that is beginning to be aggregated from medical records into meaningful population data. This is still in its infancy, but the promise for understanding disease and disability and targeting prevention and management efforts is enormous. Second to my mind is the potential growth of the role of public health and population health driven by better data pictures, but more importantly by the reality that, as the population moves toward universal coverage, some financial organizations will bear the risk for not doing something about prevention, safety, and effective management of care. This has the potential of changing many of the current dynamics around where health dollars are spent. Accountable Care Organizations are my third area for attention. There has been a lot of rhetoric and a few solid first steps, but as primary and specialty care, in-patient and out-patient, and prevention and treatment start to integrate, good things will happen. Fourth for me is the reality that, as we move toward some sort of global financing arrangements with more fully integrated systems, they will be more open to small scale innovations in technology and service that help them build a better value proposition. Such little innovations drive much of the change in information technology (just think about apps and their impact) and the stage is just about ready to welcome them in health care. Finally, these last two developments will help usher in and speed up the growth of the role of the consumer/patient in health care. In fact, I think many of the new things that change the reality of health care will first be purchased by consumers, independent of providers.
Will we have any fun along the way?
Is this trip just a slog of a march that we have to take in order to do something that must be done? Or is it a journey of discovery where we might bring to bear those admirable virtues of American society: fairness, justice, and the American economy, with its hallmark innovation, creativity, and consumer responsiveness, to address a problem that continues to perplex us: the delivery of health services. The real genius of this reform framework is that it promises to awaken these elements of our better nature. But to activate this will require courage and openness toward how we approach health care, something that we would like to be characterized by certainty and predictability.