Moving from Obamacare to Health Care Reform
The Affordable Care Act, upheld by the Supreme Court in June 2012, set forth the most ambitious health care reform since the creation of Medicare and Medicaid in 1965. President Obama's plan – popularly referred to as Obamacare – expanded coverage to millions of Americans by allowing young people to stay on their parents' insurance until age 26, removing pre-existing condition restrictions for those seeking insurance and by requiring small businesses to offer health insurance coverage to employees.
The plan also set in motion initiatives to create integrated care facilities and to start a transition towards digital health records nationwide. All of these reforms are likely a good thing for the country; however, one major problem remains: the system is still broken.
The United States health care system operates under what is known as a "fee for service" system, where a doctor--or provider of another type, such as a clinic or hospital-- is paid for the specific services provided to the patient. See a doctor for a routine checkup? Pay the fee for a routine checkup. Have a knee replacement? Pay for the knee replacement and the hospital costs. Whether it is an individual or an insurance company paying for the services, the system is still the same.
But what if a patient goes in to have a coronary stent put in, faces complications or infection after being discharged, and has to be readmitted to the hospital? Or what if a doctor is unable to identify the cause of a person's pain, and ends up charging for numerous visits, evaluations and prescriptions, though never actually correctly diagnosing the problem?
Dr. Mark McClellan, director of the Engelberg Center for Health Care Reform at the Brookings Institute, has toured the country addressing these issues. McClellan has also served as commissioner of the U.S. Food and Drug Administration, an administrator for the Centers for Medicare and Medicaid Services and as an advisor to the White House on domestic and economic issues.
In a presentation entitled "The Future of the Affordable Care Act", McClellan has laid out a series of changes that can provide more meaningful reform. These suggestions focus on providing better care, while reducing costs without restricting access.
First, McClellan stresses switching the focus of health care from the treatment of acute problems to a system that promotes prevention. For instance, with so many conditions related to obesity – heart disease, high blood pressure, osteoarthritis and diabetes, to name a few – prevention could have a major impact. Rather than attempting to address each condition when they develop, McClellan recommends that physicians focus on weight management, diet and exercise before any of this becomes an issue.
In addition to creating a delivery system that encourages prevention, he believes America’s health care system needs to do a better job of managing chronic conditions that too often are addressed narrowly and reactively. Instead, he said, a system of coordinated care (including collaborative care facilities) could help provide long-term management of a condition and monitor a person’s general health simultaneously, likely increasing positive outcomes while reducing costs.
McClellan also encourages a shift in the way consumers think about health care, away from a scheduled face-to-face visit, and to a more intuitive, cost-effective approach. Patients could instead teleconference with doctors--(a trend which has grown significantly in the last decade--or address less severe needs with a provider other than a doctor, such as a nurse practitioner or physician's assistant. This approach would reduce the amount of time a doctor needs to spend on routine patient care and that would help alleviate the scheduling issues and wait times that many patients face today, especially in low-served areas.
In terms of the delivery of acute services, McClellan sees a great need for increased efficiency. Blood clots and other complications, along with hospital re-admissions need to be dramatically reduced, he says, as must overspending on wasted services. This includes reducing unnecessary, overutilized services addressed in the Choosing Wisely initiative.
Finally, McClellan recommends increased innovation in the development of treatments. Though the United States is the leading source of pharmaceutical research and development, there needs to be more outside-the-box thinking, McClellan argues. He sees the use of genomics and personalized medicine as the potential next steps in the field. This, too, can indicate who may be likely to develop a disease, and necessary preventive efforts can be taken before the person becomes inflicted with a condition.
But, as McClellan noted, such changes are not likely to come from Congress or the federal bureaucracy. Instead, this major overhaul must start with those who are most invested in the health care system: patients, providers and insurers.
McClellan, Mark B. "The Future of the Affordable Care Act." Driving Froces: Healthcare, Infrastructure and Virginia's Fiscal Future. George Mason University Centers on the Public Policy, Arlington, VA. 25 September 2012. Keynote Address.