Monday, May 13, 2013

A Short History of Health Reform: 2005-2013
Once more, in the diastole and systole of history, an age of freedom ended in an age of discipline.
Will Durant  (1885-1981)

We sometimes forget the history of health reform began before the passage of  the  Affordable Care Act on March 23, 2010.
For me it began in earnest in 2005 when I published Voices of Health Reform; Interviews with Health Care Stakeholders: Options for Repackaging American Health (Physician Support Resources).  At the time,  I was historian for the Center of Practical Health Reform. The book consisted of interviews with 40 prominent health care leaders.
The book had 12 “practical" conclusions.
1)       Fragmentation and conflicts among health care interest groups renders reform intractable.

2)      Single-payer backers, still committed, are seeing practical opportunities slip away.

3)       Medicare, in its present form, is unsustainable.

4)      These days the consumer-driven movements occupies everybody’s minds.

5)       Regional ideological and geographic differences matter.

6)       Hospital and physician collaboration remains an “iffy’ proposition.

7)      The consumer  movement means different things to different stakeholders .

8)      Many American physicians increasingly consider themselves a disenfranchised  minority.

9)       Medicare and managed organizations are placing their reform bets on the pay-for-performance movement.

10)  Health care systems are difficult  to manage because they are composed of individuals  and independent organizations acting in their  own best interests at the boundaries of care.

11)  Information technologies are often seen as  the Holy Grail of Health Care, but these technologies will not work if they ignore the Elephant in the Room, reluctance of small physician practices to install electronic medical records.
Overall,  I concluded, “our health system is a creature  of our culture. Americans prefer local health solutions, reject federal government mandated universal coverage with rationing, feel capable of making their own health care solutions,  seek equal access to high technologies, prefer pluralistic  payment systems, and think doctors ought to be permitted to practice democratically, making their own decision, using their clinical judgments,  free of fetters of outsiders."
I  was wrong on some these counts.  Consolidation of hospitals, physicians, and health plans is in full swing,  doctors are going to work for hospitals in unprecedented  numbers,   private practice in on the wane,  HIT and data-driven care is exploding ,  consumer-driven care is still mostly talk, regulation of physicians is increasing, and political events have fundamentally transformed health reform dynamics.

I also overlooked or failed to anticipate the looming physician shortage, as physicians, young and old, sought  refuge from reform economic pressures, the malpractice scourge, and time pressures by retiring or working 40 hour weeks in search of a more balanced lifestyle.
The historic  events included and include:
·         2005, publication of my book Voices of Health Reform, largely based on private sector considerations.

·         2008, Democrats win control of House and Senate in midterm elections

·         2008,  President Obama elected, givng Democrats control of Presidency and Congress.

·         2010,  Affordable Care enacted,  without a single Republican vote

·         2010,  Republicans win control of House in midterm elections, partly due to rise of Tea Party
and unpopularity of Obamacare.

·         2012, Supreme Court rules individual mandate constitutional but says  states may opt out of Medicaid expansion

·         2012, President Obama re-elected

·         2013,  Obamacare implementation begins under a cloud

As these events are  taking place,   the health law remains unpopular by 8% to 10% margins in polls, premiums continue to rise, especially in individual and small group markets,   employers have postponed hiring or discontinued coverage or reducing employees to 30 hour work weeks  because of uncertainties what the law means to escape or minimize expenses. . Business owners are also exploiting loopholes, such as waivers and self-funding, to avoid complying with expensive and comprehensive government approved health plans.
Republicans often portray Obamacare as a federal power-grab and a threat to individual liberty and freedom of choice.  Democrats believe  government power and  discipline are needed to expand access, reduce costs, improve quality, and reduce inequality and inequities.
This federal power and ensuing disciplinary meassures  as expressed in the 2700 page Affordable Care law and enforced by some 15,000 pages of regulation,  includes“shared savings” flowing from Accountable Care Organizations;  “coordinated care” from primary-care led  Medical Homes,   a national  interconnected electronic medical records system; an outcomes research institute for comparing outcomes;  a concerted effort to replace fee-for-service for physicians  with other forms of payment; and  an Independent Payment Advisory Board  for controlling costs.  Goverment power and discipline, unfortunately,  culminates in bureaucratic overkill,  rising costs, squelching of innovatiion, and nationalization of 20% of the American economy.
Meanwhile, at this writing, May 13, 2013, the fate of Obamacare is in the hands of politicians and voters.  The current target date for determining this fate is the November 2014 elections, which Democrats hope will not be a repeat of the November 2010 midterms,  which elected a Republican majority in the House.  Concerns are rising among Democratic leaders, that Obamacare implementation  is careening with ever increasing velocity  towards a n election"Train Wreck."
Republicans  this week will have another vote to repeal Obamacare.   And  two thirds of Republican governors and/or  their legislatures  have already  choosen  not to run health exchanges in their states and to let Washington absorb the expense and the headaches  of meeting an October 1, 2013 deadline.

The legacy of Obama, and his signature legislative achievement, often dubbed a “monstrosity” by its critics,  hangs in the balance.

History awaits the voters' verdict.

Tweet:   The modern history of health reform dates back at least  ten years, and its fate  rests in the hands of voters in November 2014.


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