Alice Rivlin, a public policy icon and still the smartest person in the room at 83, talked about Obamacare from a unique perspective last week at AcademyHealth’s annual National Health Policy Conference.
Alice helped to analyze the launch of Medicare and Medicaid as a young economist in the administration of President Lyndon B. Johnson nearly 50 years ago. Today, she’s evaluating the implementation and impact of the Affordable Care Act as director of the Engelberg Center for Health Care Reform at the Brookings Institution in Washington, D.C.
How amazing is that?
Obamacare is social legislation to rival those sweeping public health insurance programs from 1965, she said. It is also a major test of federalism, giving states the opportunity to design the law’s provisions to reflect their specific needs. She expects that states will implement the ACA differently, as evidenced by decisions on whether to expand Medicaid and how to operate their insurance exchanges as well as seeking Medicaid waivers moving forward. That variation will be a good thing, she said.
“There is a historic opportunity to learn from this great experiment,” she said. “Policy is easy. Implementation is the hard part.”
Alice has teamed with Richard Nathan of The Nelson A. Rockefeller Institute of Government at the State University of New York, another revered policy expert and teacher, to lead a longitudinal study called The ACA Implementation Research Network using a team of field researchers in 36 states (The Colorado Health Institute is pleased to be one of those field research organizations. Read our first report looking at the ACA in Colorado here.)
Four members of the CHI team – CEO Michele Lueck, Senior Director for Policy and Analysis Amy Downs, Director of Research on Coverage and Access Jeff Bontrager and me – came home energized and with much to think about. A bonus: We got to spend time with former CHI analyst Emily King, who will be graduating from Princeton’s Woodrow Wilson School with her Master in Public Affairs (MPA) degree in a few short months. Emily is the bright future of health policy.
Topics for this year’s break-out sessions are a good barometer of the health policy work underway across the nation. We divided and conquered to attend them all. We hope that our takeaways are useful for health policy leaders across Colorado.
Whenever I am at national conferences and meet colleagues from other state, I am reminded of the breakneck activity of the health policy community in Colorado compared to other states.
Colorado has acquired celebrity status with its many initiatives. The Accountable Care Collaborative in Medicaid, the expansion of Medicaid eligibility, the demonstration to coordinate the care of those who are dually enrolled in Medicare and Medicaid, the creation of an all payer claims database and the implementation of a state-based insurance exchange are just a few. Folks from other states are in awe of how many new initiatives Colorado is implementing of late.
What else was did I learn? While we all talk about the importance of coordinating the care of people who are dually enrolled in both Medicare and Medicaid, some of our most costly health care users, it’s not a topic that attracts the attention it deserves. Attendance was extremely low at a session on how to evaluate the demonstration projects that the federal government is sponsoring aimed at coordinating dual eligibles’ care in 12 states, including Colorado. Honing in on how to evaluate these demonstrations will be a long and challenging process, according to an expert panel.
A session on where providers stand on exchanging health data – or not – in order to achieve federal meaningful use standards highlighted the continuing challenges. Many providers never wanted electronic health records (EHRs), as one speaker noted, and were compelled to get them or face financial penalties.
After Congress approved significant funding to subsidize EHR purchases, a proliferation of different EHRs, some poorly tested, ensued. Many providers hastily invested in EHR systems that have been plagued with technical challenges, lack appropriate functionality to manage patients and don’t fit their practice needs.
With all of the discussion about the trend toward creating insurance products that consumers value and that lead to more consumer “skin in the game” in the form of cost sharing, it made me reflect on the opposite trend with providers and EHRs. It’s hard to make providers value something many of them didn’t want and didn’t fully pay for. They had limited skin in the game.
We don’t always make the best choices under duress.
One of my main takeaways is that many health care systems across the U.S. are undergoing “transition pains” caused by moving from paying for volume (fee-for-service) to paying for value (such as through accountable care organizations). This played out in many of the sessions I attended:
- Defining and measuring value: Paying for value means ensuring that patients receive quality health care services. A number of experts lamented the lack of uniformity in defining “value,” and the perceived duplication and significant effort expended in attempting to measure quality.
- Trying new models: A number of sessions focused on innovation: everything from getting basic primary care at your neighborhood Walgreens to integrating community health workers into primary care teams. Some models may facilitate better coordination of care, but our current payment system doesn’t always foster innovation.
- The role of the safety net: Some community health centers see the transition as “dangerous,” a resource-intensive new world with uncertain outcomes.
- Vertical versus horizontal consolidation: Horizontal consolidation in U.S. health care – such as one hospital system purchasing another – is underway. However, many systems are now consolidating vertically, with providers offering health insurance products, or hospitals buying physician groups. While vertical consolidation may facilitate better coordination of patient care within a system, it also may lead to decreased competition and higher prices overall.
I was struck by how much the discussion centered on the social determinants of health and the need to address those tough issues – poverty, housing, education, discrimination – as a crucial part of improving health.
The Robert Wood Johnson Foundation will announce a 20-year strategy refresh on May 27 that will have a greater focus on the social determinants of health, said RWJF Vice President Alonzo L. Plough. RWJF used to have a focus on health care and another on health. Now, its goal is to build one cross-sector national movement with a goal of creating equal opportunities to make healthy choices, he said.
Dr. Eduardo Sanchez, Chief Medical Officer of the American Heart Association, said his organization is now working on social determinants as well as clinical interventions to improve health. He memorably noted that of the 8,760 hours in a year, only a small percentage are spent within the health care system. The rest of those hours are where we can target our work to improve health, he said.
At Local Initiatives Support Corporation (LISC), which provides funding and support for community development projects, there is a new emphasis to include health considerations in every project, said Senior Program Director Amy Gillman. And Dr. Ana Diez Roux, dean of the School of Public Health at Drexel University, providing fascinating insights on the research into the impact of our neighborhoods on our health.
Finally, on the Obamacare front, I learned there is a great deal of trepidation by both government officials and consumer advocates about tax season. That’s because it’s possible that many people who received tax credits to buy health insurance through the marketplaces will find that they must repay some of the money in order to reconcile what they received in advance, based on estimates of their income, with what they actually report on their tax return.“The problem is that there is no relief valve,” said Judith Soloman, vice president for health policy at the Center on Budget and Policy Priorities. “People who did what they were told to do are now facing overpayments.”
The law contains caps on how much must be repaid, but Soloman suggested that the repayment be waived if the overpayment was not the fault of the customer and did not reflect fraud.
The health care workforce is an important issue in Colorado, where many areas struggle to provide enough providers to care for their residents. But I learned that health care workforce matters have been largely ignored in Congressional discussions over the past several decades. And when they do occur, the focus tends to be on budget concerns.
The dynamics of today’s marketplace, however, are forcing the issue to emerge more substantively.
Ed Salsberg, a research instructor at George Washington University, is focused on new approaches to training the health care providers of the future. The current system trains about 30,000 physicians a year, but it costs more than $15 billion annually and it’s not aligned with anticipated workforce needs, he said.
Dr. Atul Grover, chief public policy officer of the Association of American Medical Colleges, said that given what is known about consumer preferences, he advocates training in a multi-disciplinary setting; team-focused; targeting the core competencies of each team member; an environment where residents are engaged with research; and exposing residents to a care innovation framework.