The Importance of ACA on Public Health

On June 29th, 2012, the Supreme Court of the United States (SCOTUS) largely upheld the Patient Protection and Affordable Care Act (PPACA, aka Obamacare), deeming it’s individual mandate as constitutional when viewed as a tax. While constitutional, the polarized nature of today’s political and news systems have made this act the “topic of the day” for weeks now. Today’s panel discussion hosted by George Washington University School of Public Health and Health Services sought to expand the discussion to understand the public health implications that the Affordable Care Act has on the public health community, for practitioners and consumers alike.

In a one-and-a-half hour webcast and live session, health care leaders took the stage to make their case on “Obamacare” and it’s contributions to pushing forward the core mission of public health: assuring conditions in which people can be healthy. Among those speaking, Secretary of the Department of Health and Human Services, Kathleen Sebelius opened up the event with a broad background giving context to the discussion. Among a laundry list of remarks, ranging from the growing health care spending challenge, to details regarding the ACA, Secretary Sebelius touched on a few extremely important pieces of information, worthy of being tweeted and re-tweeted to any of your followers:

Regarding the history of our health care system:

  • In 2010, despite spending more than any other nation on health care, we were moving toward 50 million uninsured and mediocre results. This increase in health care spending threatened our global competitiveness. (commentary: I would venture to say that our global competitiveness in the health care arena is not only threatened, but also missing. The United States is #49 in infant mortality, #50 in average life expectancy, and among the top 10 most obese countries in the world)
  • Before the ACA, the insurance market was becoming more consolidated and much less competitive. This lack of competition left a lot of families in a broken market with rules made by insurance companies.
  • While keeping patients with pre-existing conditions out of the pool was a successful model for insurance companies (in 2009, 5 largest insurers made $12bil profit), the 129,000,000 people with pre-existing conditions that could have been either locked-out or priced-out of the market didn’t see this market as a functional system.

Regarding the Affordable Care Act:

  • The ACA was passed to address COST and COVERAGE. The first principle relates to existing coverage: If you have coverage, you keep it. Additionally, the law puts in place new rules prohibiting insurers from capping coverage or canceling without cause. To be fair, there are certain exceptions to this “grandfather” clause as mentioned here.
  • In 2012, so far, more than 16 mil people on Medicare have taken advantage of at least one preventive care service (cancer screening, wellness education)
  • 154 health care organizations have already signed up to form Accountable Care Organizations (ACOs), where providers share the savings when their patients are healthy (turning the “sickcare” system into a “wellcare” system)
  • The law gives a lot of flexibility to states in shaping their own markets. States can deign their own health insurance marketplaces, partner with HHS, or have HHS do it all. Additionally, if states can find a different way to provide coverage and lower cost, they can take over the whole system. According to Secretary Sebelius, President Obama has pushed to move this provision up from 2017 to 2014, when the insurance exchanges come into play.

In a less detailed, yet equally impactful, follow-up, Fmr. Senator Tom Daschle (D) described this time as a transformational moment, “equal if not exceeding anything our country has experienced in 200 years.” The former senator then continued by providing some general observations, noting that the US is the only country in the industrialized world without a health care system (but a heath care market), as well as giving some figures on death due to lack of service (lack of insurance).

Perhaps the most important pieces of Mr. Daschle’s speech refer to his four areas of debate, and the five qualities that the people of the US must demonstrate as we move forward with ACA.

Four areas of significant debate:

  1. Policy: as mentioned in many news outlets and by many experts, the debate over “Obamacare” is not related to it’s overall provisions, but is more related to the role of government. And while none of the legislative issues will get anywhere this year (given the elections), budget will have real traction, given the real need for cost control. The fmr. Senator gives two options. One of “cut and shift” which entails cutting spending and shifting the burden onto the states, companies and individuals, and the other referring to redesigning and improving the current budget to fit our needs. While the fmr. Senator mentioned the “redesign and improve” tactic, many of the listeners would have probably wanted more details than just a gimmicky title.
  2. Secretary: according to Mr. Daschle, the Secretary has 3 categories of focus: insurance reform (designing and creating the exchanges), payment reform (moving away from a system that rewards volume to a system that rewards value, from fee-for-service to capitation) and delivery reform (evidence-based, outcomes-based practice).
  3. 50 Challenges: referring to all of the 50 states of the US, Mr. Daschle referred to each as their own workshops where we can test, learn, tweak and improve the approaches in implementing the ACA.
  4. Political: perhaps the most ardent of all issues: who gets elected in November? As one would assume, this will have a tremendous impact on how the ACA is implemented.

Five important qualities:

  1. Resilience: to get over setbacks and unexpected events.
  2. Innovation: to think of new ways of tweaking the law, tweaking the process and reaching the milestones.
  3. Collaboration: partnership, persistence and pragmatism at all levels (public and private).
  4. Engagement: we can’t afford to let others make our decisions, therefore, we all need to be involved in the process from start to finish.
  5. Leadership: at all levels, from all backgrounds.

The last speaker to take the podium, Sheila Burke, Senior Public Policy Advisor at Baker Donelson, focused on future challenges that the ACA will likely face, such as continuing repeal/reform efforts (with the now 31 votes to repeal “Obamacare”). Ms. Burke mentions that many of the provisions in the legislation are political common ground (such as insurance and reform provisions), reinforcing Fmr. Sen. Daschle’s “role of government” argument.

The factoid that struck me the most were the 109 milestones designed for states to meet when implementing the ACA. These milestones were created by the National Academy of State Health Policy and can be found here.

While I was hoping for a heftier discussion after the speakers left the podium, some of the questions posed online were answered succinctly. Ranging from issues of provider shortages to the precedence of the SCOTUS decision, the panel of 5 experts facilitated by Sarah Rosenbaum kept focus on the subject of the discussion. My biggest disappointment in this webcast was the short amount of time dedicated to Q&A. As almost 300 online viewers glued their eyes to the computer screen, I would have assumed more Q&A time.

For your reference, the livestream recording can be found here.

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  1. George

    One could make similar policy argument for the so-called stimulus, but that massive spending bill predictably failed and the economy continues to sour; one could make similar arguments that the economy was not doing as well as it should be, but, again, that massive spending bill predictably failed and the economy continues to sour – despite attempts to pretend that somehow things would have been worse.

    Likewise, arguing what something (ACA) is supposed to do or that things could be better while ignoring the predictable negative effects of forcing a ridiculously expensive and unconstitutional bill will similarly and predictably lead to more massive costs, worse patient care, and will leave bureaucrats, rather than doctors, with the last word over your care.

    In short, this is an ill advised policy that will cost more in both blood and money in the long-run- and, moreover, is utterly unconstitutional regardless of what Obama and Roberts may want to argue. There is little doubt that the Court (Roberts) buckled under political pressure from Obama and the media; in doing so, he joined Obama in failing both the Constitution and the American people.

    • Bogdan

      I don’t think I understand what you refer to when saying “one could make similar policy argument.” Is it that a policy is intended to do this or that? That’s where policies begin….before implementation…the ACA is no different and CAN’T be any different.

      RE: ignoring the predictable negative effects: expensive? yes…I agree. But look at how expensive our current health system is…where hospitals only collect on 1/2 of their bills and double the price for the rest of us. We’re not talking about a policy to change the speed limit or the legal drinking age. This is a policy to affect not only the patient, but providers, health care administrators, public health practitioners etc. Give me an example of a cheap solution…

      Regarding its constitutionality, the point of my post wasn’t to debate whether it’s constitutional or not. That’s not my place as I am not astute in the ways of the law.

      If this was such an ill-advised policy, I would have assumed that not many practitioners would be intrigued (positively) about it. You can google examples of ACOs forming PRIOR to the court’s decision (ACOs being part of the legislation). You can google docs and patients commenting on the positive coming out of this law (as much as you can also google the opposite, no doubt).

      I tried to be as least political as possible, as I try in most of my posts. Is the policy ill-advised because in your opinion, its unconstitutional? Or is it ill-advised because of SPECIFIC points?

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