It is this week we are to hear the Supreme Court rule on the constitutionality of the Affordable Care Act (ACA), the mandate to purchase health insurance in particular. The court announced the day to introduce the decision will be Thursday June 28. What hangs over the opinion is a debate about one or more aspect of the law, what Justice Ginsburg implied in a recent appearance described was close and contentious. It is irresistible to speculate what bedevils the court is the lack of a limiting principle to guide the individual mandate. Despite this controversy, court watchers predict the reminder of the law will stand.
Perhaps that single provision deserves criticism; it comes off as a legislative contrivance to avoid a new tax, as a something for everyone to hate. But, yesterday morning Tom Brokaw expressed on Morning Joe the powerful sentiment ‘if not this law then what?’ Something in harmony with the following poll:
"an Associated Press-GfK poll shows that more than three-fourths of Americans do not want their political leaders to leave the health care system alone in the event the court throws out the health care law"
One way to see how little controversy the law has is to look how large portions of the bill have and will proceed no matter what the decision Thursday. In the last six years this region of New Hampshire has seen the emergence of a plan to an integrate health care. The Granite State Health network was announced in 2012 and is the destination for these efforts. Practices already are linked to the particular hospital in their area; specialists communicate with PCPs by the electronic medical record. That means also spcialists are communicating with other specialists. It is not just helpful, it is what patients expect is going on. Within the walls of the hospital we have rapid response teams that have reduced the number of bad outcomes, reduced ICU utilization. A culture of safety in emphasized. Communication with pharmacies in and out of hospitals has reduced the amount of unnecessary and injurious care. All of these efforts are part of the Affordable Care Act (ACA).
Don Berwick, former head of The Centers for Medicare and Medicaid Services (CMS),summarizes it best without to much policy jargon. According to Dr. Berwick improving the U.S. health care system requires simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health care. Much of the ACA is devoted to this last point, on areas of waste and inconsistency.* CMS is implementing these provisions and after Thursday these initiatives will continue.
•Failures of Care Delivery: the waste that comes with poor execution or lack of widespread adoption of known best care processes, including, for example, patient safety systems and preventive care practices.http://jama.jamanetwork.com/...
•Failures of Care Coordination: the waste that comes when patients fall through the slats in fragmented care. The results are complications, hospital readmissions, declines in functional status, and increased dependency, especially for the chronically ill.
•Overtreatment: the waste that comes from subjecting patients to care that, according to sound science and the patients' own preferences, cannot possibly help them—care rooted in outmoded habits, supply-driven behaviors, and ignoring science.
•Administrative Complexity: the waste that comes when government, accreditation agencies, payers, and others create inefficient or misguided rules.
•Pricing Failures: the waste that comes as prices migrate far from those expected in well-functioning markets, that is, the actual costs of production plus a fair profit.
•Fraud and Abuse: the waste that comes as fraudsters issue fake bills and run scams,28 and also from the blunt procedures of inspection and regulation that everyone faces because of the misbehaviors of a very few.
For those of us on the front lines (so to speak) of medicine, we see it as a war against bad outcomes. Its a physical, moral, and emotional challenge that comes with an ancient mandate to provide care. I would hope that should easily be seen as a mandate for all to contribute, no less important to people than feeding or defending ourselves. Yet we have this unexpected furious debate that is wearisome and misguided. If the ability to feed ourselves was threatened would we be debating whether the constitution allows us to bend an individuals choice? Would a similar critique be applied to a draft? At the risk of digressing into picayune history, this political debate is like the draft riots in New York during the civil war which seem so misguided and shortsighted today. To borrow a phrase from the conservative judge Laurence Silverman can we see the law as an effort to ‘forge a national solution?'
Another way to see how little controversy the law has is to look to the alternatives. Several influential GOP lawmakers have sponsored comprehensive bills that in some ways resemble the ACA, with health insurance exchanges, subsidies for the uninsured to buy coverage, and insurance market reforms. Paul Ryan in the house has a proposal that is a nonstarter; it simply shifts costs without a plan to remedy a strained private sector unable to control cost and which limits access as a result. The senator from Oklahoma Tom Coburn—a physician, also a contradictory if not insensitive and vocal critic of the bill during its construction in 2009—has a bill to offer if the entire act fails. He loses me in his rhetoric, but his work with Joe Lieberman looks like it leaves aside insurance reform and its problems with affordability and instead focuses on Medicare alone. This leaves alone the long-term insolvency of hospital insurance, as the Ryan plan does. Both keep us rationing care by rationing people to use a formulation from of Oregon Governor John Kitzhaber.
By the way, any national healthcare reform act under a President Romney is predicted to be a reform of private insurance. Yes, he expected to abandon his famous efforts in Massachusetts and follow the GOP wish for purchasing insurance across state lines; this is without a national remedy for the race to the bottom in quality and coverage:
Beyond repeal, Romney said that he favors letting states come up with their own solutions to the problems of the uninsured, healthcare costs, and quality gaps. His brief reform outline would:From this lineup I am no longer left wondering if republicans, conservatives, and especially Mitt Romney ready to own this on Friday. The GOP is clearly unprepared for what they wish for. I say they do not seem to have a vigorous alternative in waiting let alone having the will to fight a reform through congress. While we wait for their plans and will, millions of twenty-somethings will be thrown off insurance rolls. Preexisting conditions clauses will be reinstated. They will even let stand the ‘donut hole,’ a mess they created with the Medicare part D which is a painful, absurd challenge to patients and physicians. (It is this time of the year onward that we have gaps in our schedules from many seniors not being able to afford drugs or other medical care in the latter parts of every year.)
•Allow health insurers to sell policies across state lines, free from state benefit mandates;
•Require insurers to offer policies to people who have been continuously insured regardless of preexisting medical conditions;
•Let individuals and small businesses form purchasing pools to buy less expensive coverage;
•Cap noneconomic damages in medical malpractice lawsuits and encourage alternative dispute resolution;
•Encourage high-deductible health savings account plans by eliminating deductibility rules; and
•Help states develop mechanisms for covering people with chronic illnesses and other preexisting medical conditions.
On Medicare, Romney proposes to give seniors a voucher -- called "premium support" -- to buy coverage from either the Medicare fee-for-service program or a private plan. He also would raise the eligibility age by an unspecified number of years. On Medicaid, he would give states more control by converting open-ended federal funding into capped block grants. Both of these proposals lack key details, such as the annual rate of increase in the Medicare voucher and block grants.
Most of all do they not have a plan for what the insurance companies themselves will do after their lobbyists arrive at capitol hill. Leave aside the new goals to provide guaranteed issue (ignoring preexisting conditions and medical complexity) and community rating (finding fair and faffodable insurance rates,) the reality is their business model is going the way of commercial whaling—ever extreme efforts for ever decreasing service.
Let me leave with another reality; that supports the possibility—at least the possibility—that the law will stand in its entirety. The healthcare system that evolves from the provisions of the Affordable Care Act is not going to have insurance companies as we know them. In the future we will see hospital systems working with patients and entities such as Medicare, the Veterans Health Administration (VHA) and ‘insurance providers’ to help provide health care to citizens.
One model for this fused entity is the Accountable Care Organization (ACO). I mention ACOs because serving the existence of an institution such as this can be construed as something different that purchasing insurance; it is contributing to a health security provider. According to the Centers for Medicare and Medicaid Services (CMS), an ACO is "an organization of health care providers that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it." But this can be applied to patients outside of Medicare. It is true that now just under half of the patients served by hospitals are Medicare patients and that portion will rise to over 60% by the end of the decade.
Other models exist here in New Hampshire such as the self-insured Dartmouth Hitchcock center touted throughout the 2009 debates as an example of one of the best integrated medical systems. Another, perhaps, is the single payer system being developed in Vermont. Vermont is forging a single payer system that provides universal coverage system with the inclusion of healthcare insurance companies in the process. “for individuals and small businesses that participate in the federally mandated insurance “exchange,” which provides tax credits and subsidies for those who qualify.” They hope to do this wihout an individual mandate.
I subscribe to Medscape and apologies are in order because it is a password-protected site. Its free but password protected
* In another venue the former head speaks of two goals for the Affordable Care Act 1) improvement in coverage and 2) improvement in quality. Quality and cost are intertwined.
Thu Jun 28, 2012 at 9:58 AM PT: I did not know crow was so sweet a thing to eat
Thu Jun 28, 2012 at 9:59 AM PT: I did not know crow was so sweet a thing to eat