Short History of Health Reform: 2005-2013
more, in the diastole and systole of history, an age of freedom ended in an age
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
The book had 12 “practical" conclusions.
1) Fragmentation and conflicts among health care
interest groups renders reform intractable.
backers, still committed, are seeing practical opportunities slip away.
3) Medicare, in its present form, is
days the consumer-driven movements occupies everybody’s minds.
5) Regional ideological and geographic
6) Hospital and physician collaboration remains
an “iffy’ proposition.
consumer movement means different things
to different stakeholders .
American physicians increasingly consider themselves a disenfranchised minority.
9) Medicare and managed organizations are placing
their reform bets on the pay-for-performance movement.
care systems are difficult to manage
because they are composed of individuals and independent organizations acting in
their own best interests at the boundaries
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
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
President Obama elected, givng Democrats control of Presidency and Congress.
Affordable Care enacted, without
a single Republican vote
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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