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Chapter 1 - Health Reform

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CHAPTER 1 - HEALTH REFORM

Content Last Updated: 5/22/2013 3:47:18 PM
Graphics Last Updated: 3/21/2012 11:46:45 AM
Note: Terms in green will show glossary definitions when clicked.

Originally written by Joanne Kenen, then of the New America Foundation, and updated by Joanne Kenen and Deanna Okrent, Alliance for Health Reform. Last updated by Michael Berger, November 7 , 2012.

FAST FACTS

  • In its original form, the health care reform law – or the Affordable Care Act (ACA) – enacted in March 2010 was expected to reduce the number of uninsured nonelderly people by an estimated 32 million.1
  • The Supreme Court on June 28, 2012 upheld the individual mandate of the Affordable Care Act, ruling that the mandate is constitutional in that it should be considered a tax.
  • The court ruled, however, that states do not have to participate in the law’s Medicaid expansion. See the Medicaid chapter for details.
  • Based on the Supreme Court decision, the Congressional Budget Office (CBO) now estimates that the Affordable Care Act will reduce the number of uninsured nonelderly people by 14 million by the end of 2014 and by 29-30 million by the end of the decade.2
  • According to the most recent U.S. Census Bureau surveys, between 2010 and 2011, the number of nonelderly people without health insurance decreased for the first time in four years from 50 million to 48.6 million. The overall percentage of people without insurance dropped from 16.3 percent to 15.7 percent in the same time span.3
  • As of 2011, 63.9 percent of the population was covered by private health insurance 32 percent of the population was covered by public health insurance, 16.5 percent was covered by Medicaid, and 15.2 percent was covered by Medicare.4
  • One of the provisions already in effect from the Affordable Care Act allows children to stay on their parents’ health insurance until age 26. Much of the increase in insurance coverage between 2010 and 2011 is attributed to this provision, as the number of uninsured individuals aged 19-25 decreased by 539,000 in that time span.5
  • An estimated $2.6 trillion was spent on health care in the United States in 2010, almost 18 percent of the Gross Domestic Product (GDP).6
  • According to the most recent report by the CBO (March 2012), the Affordable Care Act is estimated to cost $1.083 trillion, though this estimate does not incorporate recent changes to the law as a result of the Supreme Court ruling.7
  • Health care reform is expected by CBO to save $124 billion over 10 years, and bring down the federal budget deficit by about one-half percent of GDP in the next decade.8
  • Repeal of the ACA would increase federal budget deficits by about $210 billion in the period 2012-2021, according to CBO analysis.9

BACKGROUND

National health reform efforts have surfaced and resurfaced in the United States for more than a century. Before 2010, none had garnered enough popular support and congressional support to enact a federal law that came anywhere near the goal of universal coverage.

What was different this time around? Did the economy, the burgeoning federal deficit, the aging of the population, the obesity epidemic, its consequent chronic diseases, and the development of high tech medicine cause double digit increases in health care costs and inspire health reform? Or did the political climate and a new president placing a high priority on health care issues start the proverbial ball rolling?

In any case, we began a new health reform story on March 23, 2010, when President Barack Obama signed the Patient Protection and Affordable Care Act into law. (The law is commonly referred to as the Affordable Care Act or ACA.)

The legislation, expected to result in an estimated 30 million uninsured Americans getting health coverage by the end of the decade,10will begin to redesign a fragmented, uncoordinated and highly expensive health care system. The new law was the fulfillment of a goal sought by reformers, with varying degrees of intensity, since Theodore Roosevelt introduced the idea of coverage for all in the 1912 Progressive Platform.

As President Obama noted, it was a “remarkable and improbable” achievement.11Yet in our current polarized environment, it remains fraught with political and policy uncertainties that could shadow, even threaten, implementation in the years to come.

The U.S. Supreme Court cleared up some uncertainties with its 5-4 ruling in June 2012 that the law is constitutional, except for the provision that threatens states with a loss of all their federal Medicaid matching funds if they refuse to implement the law’s Medicaid expansions. States can now keep their federal matching funds for existing Medicaid beneficiaries, even if they decline to expand eligibility as called for in the reform law. (See the Medicaid chapter for more.)

Historically, our discussions of national health reform focused on coverage. This time, the case was made that health reform is greater than coverage alone. Coverage, cost and quality, reform proponents argued, are intrinsically entwined, and cannot be addressed by piecemeal or incremental solutions.

Our system, rooted in a mid-20th century acute care model, does not adequately meet the health care or economic needs of the 21st century, where the overarching medical challenge, and expense, flows from chronic disease in an aging population.12

It was also argued that the cost of inaction outweighed the cost of action,13and that state and federal governments, large and small businesses, and ordinary American families needed relief from the unrelenting and unsustainable upward march of health care costs.14They convinced a majority of lawmakers, albeit a narrow Democrats-only majority, that covering the uninsured in a revamped and modernized high quality health care system is the morally and fiscally responsible path forward.

Health care reform is difficult because it’s big and complicated, with lots of moving parts and potential unintended consequences. It affects more than one-sixth of the economy, and touches every doctor, hospital, and community. It’s also hard because even in less volatile political times, Washington debates over health issues are not always about health care per se, but about politics, power, and the size and reach of government. It is because of these factors that the debate goes on well after passage of the law.

The nation and Congress remain divided over health reform. Public opinion polls show a country closely divided between those in favor and those opposed to the law.15

Republicans in Congress pledge to repeal parts or all of the law, or starve the remaining unfunded provisions of the law. In January 2011, the Republican majority in the House of Representatives voted to repeal the ACA entirely. (The repeal bill failed in the Democrat-controlled Senate.)

Action on repeal would face a veto from President Obama.

IMPLEMENTATION

The 18 months of debate and the opening phase of implementation were shaped by an interesting paradox. As Professor Robert Blendon of the Harvard School of Public Health has explained, many in the U.S. are skeptical about “health reform” but support many of reform’s components, such as creating health insurance exchanges, subsidizing the poor, or requiring insurers to cover people with pre-existing conditions.16Reform’s success in the long term will be determined in part by whether and when the American public decides that health reform is the sum of its reasonably popular parts and how well implementation proceeds.

The federal government and the states have a shared role in implementation. Federal agencies have responsibilities ranging from direct implementation of some provisions in the law to discretionary decision-making with regard to other provisions. States also have had to move quickly on their options with regard to designing health insurance exchanges. At the same time they are dealing with budgetary challenges, legislative calendars and administrative transitions resulting from the November 2010 elections. (For more detail see the Alliance issue brief, “Implementing Health Reform: Federal Rules and State Roles,” at www.allhealth.org/pubs_issuebriefs.asp.)

Stakeholders – physicians, hospitals, insurers, employers and consumers, to name just a few – will also be affected by how the law is put into effect.Many are actively engaged in the process, in rulemaking on the federal level and in their state politics.

COVERAGE

As noted, the health care reform law will result in coverage for an anticipated 30 million Americans and legal immigrants – 11 million through the biggest-ever expansion of Medicaid.17The percentage of insured nonelderly residents (excluding illegal immigrants) is expected to increase from 82 percent in 2012 to 92 percent in 2022.18About 30 million nonelderly residents (close to one fourth of whom are undocumented immigrants19) will remain uninsured.

Although only Democrats voted for the final legislation, the bill itself was an amalgam of ideas from both parties. The individual mandate, for instance, was initially a Republican idea that came to prominence during President George H.W. Bush’s administration.20

The new health care law is a hybrid of public and private solutions. It maintains the current employer-based system but fills in the gaps by attempting to expand public programs, notably Medicaid, and devotes more resources ($11 billion from FY 2010-15) to community health clinics.21It creates “exchanges” or purchasing pools starting in 2014 to help individuals and small business purchase affordable and reliable coverage.22

The state-based exchanges, which according to the Congressional Budget Office will cover about 24 million people by 2019, will have to follow new rules and will provide new consumer protections.23(Not everyone who will be covered in the exchanges is currently uninsured, nor will all individuals in the exchange be subsidized. Undocumented immigrants will not be allowed to buy plans within the exchanges.)

Insurers will have to cover everyone, including people with pre-existing health conditions. They won’t be able to charge a higher premium based solely on a person’s health status.24There will be limits on how much individuals and families will have to pay out of pocket in any year, and plans will include better coverage for preventive care. (Other consumer protections come into play earlier.)

The “public plan” – an option for a government-sponsored health plan within the state exchanges – was dropped from the final legislation. Exchanges will instead contain nonprofit co-op plans, as well as national plans negotiated by the federal government but privately run by insurers. (For more details on the exchanges and the new regulatory framework, see the Kaiser Family Foundation’s summary at www.kff.org/healthreform/upload/8023-R.pdf).

The health reform law calls for shared responsibility – government, individuals and businesses all have obligations. People who do not buy insurance, or businesses that do not cover their workers, will face penalties. Small businesses and low-income individuals will receive subsidies, and there will be some exemptions based on affordability. People can get subsidies on a sliding scale up to 400 percent of the federal poverty level. (See the Cost chapter for details on coverage levels and subsidies.) (For more details, go to www.kff.org/healthreform/upload/8023-R.pdf.)

The health reform law gradually closes the “doughnut hole” or coverage gap in the Medicare prescription drug benefit,25expands preventive care coverage in Medicare (and Medicaid), and covers annual physicals and wellness visits for Medicare beneficiaries.26

COST AND FINANCING

The nearly $1 trillion coverage expansion will be funded in part by higher Medicare payroll taxes on upper income families, excise taxes on so-called “Cadillac” health insurance policies, and fees paid by pharmaceutical companies, hospitals and insurers. Payments to Medicare Advantage, the private Medicare plans, will be restructured to eliminate overpayment. The health reform law includes neither a cap on overall health spending, nor government-imposed rationing, although opponents of the legislation maintained that some provisions – evaluating the effectiveness of different treatments, for example -- could eventually lead to rationing.

Constraining health care spending was part of the health reform debate from the very beginning. Some of the projected savings will come from “delivery system” reforms and changed payment incentives. These involve strategies to shift the health care system to some extent away from its acute care orientation, and more toward care of patients with chronic disease, which is responsible for about 75 percent of our national health expenditures.27(More than 80 percent of Medicare costs are spent to help those with multiple chronic conditions.28)

The legislation includes numerous incentives, pilot projects, demonstrations and experiments designed to create a more integrated and coordinated system, while simultaneously improving quality and restraining cost growth. New tools include medical homes, accountable care organizations, and bundled payments for episodes of care. (See "Quality" section below and Chapter 3, "Quality of Care.")

One of the new cost containment tools will be the Independent Payment Advisory Board, which will make Medicare payment and waste-reduction recommendations to Congress (although hospitals are exempt through 2019). Another is the new Center for Medicare and Medicaid Innovation, which will allow new patient-centered care models to be tested, recalibrated, and introduced system-wide with more speed and flexibility than traditional demonstration projects.29

In addition, the legislation creates a pathway for approval of biogenerics (drugs based on biologically active substances), steps to strengthen the primary care workforce, and a new Patient-Centered Outcomes Research Institute to oversee federally sponsored comparative effectiveness research to determine which drugs, devices or procedures work best. 30(See Chapter 2, "Cost of Health Care.")

QUALITY AND ACCESS

We all have heard the statement that the United States has the best health care in the world. We can no longer take this for granted. (See chart, "Medical, Medication and Lab Errors Among Sicker Adults, U.S. vs. Other Countries") Our health care markers in several areas lag behind other industrialized nations, even though we spend much more per capita and a higher percentage of our GDP.31

A 2010 survey of 11 countries – Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom and the United States – by The Commonwealth Fund found that one-third of U.S. adults went without recommended care, did not see a doctor when sick, or failed to fill prescriptions because of costs. This compared with as few as 5 percent of adults in the United Kingdom and 6 percent in the Netherlands. The U.S. ranked last among the group of eleven countries on this dimension. Another example in which the U.S. lags behind many other countries lies in access to primary care when sick. Only 57 percent of adults in the U.S. saw their doctor the same or next day when they were sick, compared with 70 percent of U.K. adults, 72 percent of Dutch adults, 78 percent of New Zealand adults, and 93 percent of Swiss adults. 32

In the last few years, the dialogue about health care quality has begun to change in Washington. More experts have concluded that we need to shift resources and priorities into primary care, care coordination, prevention and wellness.33The health reform legislation begins to do this, by experimenting with new ways of paying doctors and hospitals, rewarding care management and coordination, and beginning to shift the system to reward quality, not quantity. (See Chapter 3, “Quality of Care,” for details.)

Many of these provisions in the legislation are modest steps or experiments, focused on government-run programs like Medicare and Medicaid, and it is not clear how quickly or powerfully they will ripple through the whole health care system. The law, however, requires the adoption of a national quality improvement strategy, which includes wellness and population health, as well as a new effort to document and address health care disparities.

Among the tools that aim at creating a high performing health system:

CHRONIC DISEASE MANAGEMENT, MEDICAL HOMES AND ACCOUNTABLE CARE ORGANIZATIONS


The Centers for Disease Control and Prevention (CDC) says 80 percent of older adults live with one or more chronic diseases such as hypertension, diabetes or asthma. Half of older adults have at least two chronic conditions.34CDC also estimates that chronic disease accounts for 70 percent of U.S. deaths35and more than 75 percent of health care costs.36(See text box, “Four Common Causes of Chronic Disease.”) Much of the growth in Medicare spending in recent years is attributable to chronic conditions, especially diabetes and hypertension.37The health reform law encourages the development of "medical homes" where doctors are paid to manage and monitor chronic diseases, and while medical homes may be part of the solution, more research is still needed.38

The legislation also encourages Accountable Care Organizations, encompassing new relationships between primary and specialty care doctors and hospitals. Using a more integrated and evidence-based approach to care, providers will have to meet quality benchmarks but can share in savings from Medicare or Medicaid. (See Chapter 3, “Quality of Care,” for more.)

WORKFORCE/PRIMARY CARE

Delivery system reform is looking to primary care as an important factor in the quality, value, cost saving equation. To expand access to primary care services, the health reform law improves Medicare and Medicaid primary care reimbursements (although the legislation specifies these improvements only for the next five years in Medicare and only for 2013 and 2014 in Medicaid). The law also contains other incentives, including a reallocation of Graduate Medical Education residency training slots to encourage medical students to pursue careers in primary care and general surgery. However, these measures may not be sufficient to alleviate what some analysts consider to be a critical shortage in the primary care physician workforce. Many point to how long it takes to train physicians, how few graduates are choosing primary care and where physicians choose to practice. The latter can cause shortages through maldistribution of the workforce.

Some argue that nurse practitioners can meet part of the primary care demand.39Nurse practitioners are registered nurses with master's or doctoral degrees and advanced clinical training. The legislation expands education, training and loan support for nurses and nurse practitioners. It also includes pilot programs that rely on team-based care and an expanded role for advance practice nurses and physician assistants. Such models could result in the more efficient use of the health care workforce and extend the reach of primary care providers. Successful programs can be expanded at the discretion of the Secretary.

An October 2010 report by the Institute of Medicine recommended that nurses be allowed to practice to the full extent of their education and training. It suggested that the federal government might promote reform of states’ scope of practice laws by sharing and providing incentives for the adoption of best practices.40

The ACA also contains many workforce provisions beyond those that support and encourage primary care. For example, it establishes grants for staff training and other patient protection and quality improvements for nursing home and other long-term care facilities.41

PAYMENT REFORM

The legislation contains financial incentives for hospitals to reduce unnecessary readmissions and bring down rates of hospital-acquired infections and related conditions.

It authorizes tests of bundling, or paying a team of providers for one episode of care across several health care settings in a way that rewards quality, coordination of care among providers and outcomes.42It creates Community-based Collaborative Care Network Programs which aim to improve chronic disease treatment and management in outpatient settings.

HEALTH INFORMATION TECHNOLOGY


Physicians have been slow to embrace health information technology (IT) and most still write prescriptions on paper, though the trend among office-based physicians to adopt electronic medical records or electronic health records (EMR/EHR) has been increasing. The National Center for Health Statistics revealed that in two 2009 surveys 21.8 percent of physicians reported having a basic system and about 6.9 percent reported having a fully functional system. The estimates for 2010 are 24.9 percent and 10.1 percent respectively.43

An American Hospital Association survey conducted in 2012 found that “the percentage of hospitals that had adopted EHRs has more than doubled from 16 to 35 percent between 2009 and 2011”.44The HHS Office of the National Coordinator for Health IT, in reporting the survey, also noted that the Centers for Medicare and Medicaid Services (CMS) have made over $3 billion in incentive payments to health care providers who have started to meaningfully use EHRs, and 85 percent of the hospitals surveyed reported that they intend to take advantage of these incentive payments by 2015.45

Barriers to wider adoption include cost, debates over who should pay, worries about obsolescence, steep learning curve, concerns over maintaining patient privacy and lack of interoperability among health IT systems.46

The American Recovery and Reinvestment Act of 2009 pledged almost $20 billion in government funding to assist and incentivize “meaningful use” of health IT. The CMS priorities for “meaningful use” of IT include improving the quality, safety, and efficiency of health care, reducing disparities and improving public health, improving care coordination and engaging patients, and ensuring privacy protections for personal health information.47To date, the CMS has distributed almost $7 billion in incentive payments to 143,000 physicians48

The ACA provides additional support for health IT, requiring the development of national standards for the management of data collection, interoperability among HIT systems and security systems for data management.49

In the public health arena, large pools of privacy-protected data could lead to early identification of epidemics or bioterrorism, and help comparative effectiveness research.

PUBLIC HEALTH

Employers and states are putting new emphasis on wellness and prevention, particularly regarding obesity, exercise, tobacco use and diabetes prevention and management. (See Chapter 12, "Public Health," for more.) The health legislation allows more leeway for employers to link workplace wellness to insurance premiums.

The public has gained increased awareness of the childhood obesity epidemic thanks to the attention of First Lady Michelle Obama. The health reform law appropriates $25 million for CMS to carry out the CHIPRA Childhood Obesity Demonstration Project during FY2010 – FY2014.50

The law also establishes a National Prevention, Health Promotion, and Public Health Council within HHS, chaired by the Surgeon General. The role of the Council is to coordinate leadership on prevention, wellness, and health promotion policies and activities across federal agencies and to develop a national strategy that sets specific goals and objectives for improving population health. Bioterrorism legislation since the September 11 attacks has helped modernize the public health infrastructure in ways that enhance emergency preparedness for either a natural epidemic or a bioterrorist attack. The reform legislation provides grants to help public health agencies improve surveillance of infectious diseases and other public health problems, and respond to these threats.51

Public health researchers have stepped up efforts to understand and address the persistent and sometimes perplexing racial and socioeconomic disparities in our health care system, and the health reform law encourages further work in this area. (See Chapter 10, "Disparities," for more.)

THE UNKNOWNS AND UNRESOLVED

Health reform represents a massive change. Some of the forecasts about its effects are educated guesses based on models and assumptions – assumptions about economics, health and the future actions of politicians as well as health care providers. Concerns remain, in particular, about whether competition, regulation, and administrative simplification in the state insurance exchanges will make insurance affordable for the middle and lower-middle class.

Health reform, and its implementation, is also a work in progress. Congress takes up some aspect of Medicare, Medicaid or health policy almost every year. Sometimes it’s a small tweak to payment formulas. Sometimes it’s a sea change, like covering AIDS drugs or providing Medicare to the disabled, or covering poor children under the Children’s Health Insurance Program.

The 2010 reform legislation will need tweaks, adjustments, and possibly over time, major amendments. States too will continue to experiment on their own. Some insurers and health plans may resist change; others may find their economic self-interest and the health interests of the population they serve coincide.

And this assumes that announced efforts by some Republicans, including the House leadership, to repeal the law will continue to be unsuccessful and that appropriations for various provisions are forthcoming. Current House leadership has made a promise to Republicans and their constituents to work towards repeal of the law. Repeal is considered unlikely by many policy analysts especially considering the Democrats retained control of the White House and the Senate in the 2012 election, but the efforts will take much energy and possibly critical funding away from fully implementing the ACA.

In addition, the United States faces deep deficits for years to come. The health sector is unlikely to be off limits to a national debt-reduction strategy. Lawmakers pondered, and discarded, dozens of potential revenue raisers for health reform, ranging from taxes on sugary soft drinks to sweeping changes to the tax code.52Expect to see many of these ideas resurface in a new context as the nation grapples with its deficit and debt.

In December 2010, the bipartisan deficit commission appointed by the president issued a report and recommendations that addressed health care spending in a number of areas.53The commission recommended first reforming both the formula for physician payments (known as the Sustainable Growth Rate or SGR) and the CLASS Act, and finding savings throughout the health care system to offset the costs of those reforms.

With regard to physician payment, the commission recommended replacing the reductions scheduled under the current formula with a freeze through 2013 and a one percent cut in 2014. It also recommended that CMS develop an improved physician payment formula that encourages care coordination across multiple providers and settings and pays doctors based on quality instead of quantity of services. This recommendation supports other provisions in the law that relate to reforming the delivery system.

TIPS FOR REPORTERS

  • One of the most common errors reporters make is equating universal health care with government-run or socialized medicine. They aren't the same thing, even if some politicians claim they are. Socialized medicine means that hospitals are owned by the government, and most health providers are government employees. Universal health care simply means that everybody is covered: whether in a public system, a private system, or as is the case under U.S. health reform, a public-private hybrid.54
  • More health care does not always equal better health care. Get familiar with the basic ideas of the Dartmouth Atlas of Health Care (www.dartmouthatlas.org). In more than 30 years of work, the Dartmouth researchers have discovered huge differences in how people are cared for in different parts of the country. Regions that spend more on very sick people do not necessarily have better outcomes. In fact, lower-spending regions often show better results, partly because they tend to use more primary care and proportionately fewer specialists.55
  • Health policy as an academic field has grown tremendously since the early 1980s, in and outside of Washington. And nowadays it's all online, which makes the Washington think tanks more accessible to regional reporters. In addition, journalists can now tap into expertise in health or public policy departments at local universities. These academic experts can both help translate national policy and explain the impact of national proposals on a specific region or state.
  • Almost every story can be a health care story. Whether a reporter is covering a labor dispute, the local economy, personal bankruptcy, local politics or early childhood well-being, health care can nearly always be part of the picture.
  • More clinicians and provider groups have begun to encourage health care improvements on a local scale. Identify innovators in your community through organizations such as the Robert Wood Johnson Foundation, the Institute for Healthcare Improvement, and the American Academy of Family Physicians. Learn through your local hospitals and medical associations which providers are taking part in national pilot and demonstration programs, and which health plans may be backing innovation in the private sector too.
  • Find out what's unique about your state's health care system. Many states and governors are testing their own approaches to more affordable coverage and more integrated or evidence-based delivery of care. The State Coverage Initiatives program, sponsored by the Robert Wood Johnson Foundation and administered by AcademyHealth in Washington, DC, keeps tabs on reforms at the state level (www.statecoverage.org). The National Academy for State Health Policy is another useful resource (http://www.nashp.org/).
  • The Association of Health Care Journalists (www.healthjournalism.org) has links to many resources, webcasts, and tip sheets of use to reporters covering reform.

STORY IDEAS

  • How is your state participating in implementation of health reform? Has your state’s legislature passed any companion laws, named a health reform commission, staffed up their department of health and human services or other relevant state agency in preparation for changes due to reform? Is your state challenging the health reform law through the courts and, if so, what does that mean for citizens seeking health coverage?
  • The health reform law was expected to result in an increase of about 16 million new Medicaid beneficiaries. Medicaid is already a significant share of many state budgets. How will the Supreme Court decision affect your state’s willingness to expand Medicaid? What is the current level of poverty that qualifies one for Medicaid in your state? Will the new national standard -- 133 percent of the federal poverty level -- be higher or lower than your state’s current qualifying level?
  • What decision has your state made about a health insurance exchange as to what type it will be, who will run it and which health plans will be able to sell their products through it? Is your state seeking a Medical Loss Ratio (MLR) waiver?
  • Does your community have a primary care shortage? How easy is it to get a primary care doctor? What is your state or community doing to encourage more doctors to go into primary care? Understand the role of primary care providers as care coordinators, not necessarily as HMO-style gatekeepers.
  • "Medical homes" are appearing in numerous communities. A definition from the American Academy of Pediatrics: "Primary care that is accessible, continuous, comprehensive, family centered, coordinated, compassionate and culturally effective."56Are there medical homes in your community? If so, what do they look like? How can patients access them? What is it like to be a patient in one of them? Is this a genuine innovation or new name for primary care?
  • Spend some time with local medical students. How much do they know about the health care system that they are entering? What fields of medicine interest them as a career? What factors influence their choice of residency or specialization? Where do they hope to practice and why? How much debt do they have resulting from their educational path? Is a new medical school being built in your area?
  • Your local emergency room is a barometer for the health of your community’s medical system. Is it crowded? If so, it may be not only because of the growing numbers of uninsured. Explore how much of the overcrowding in your community is due to lack of insurance, how much is caused by the inability of the insured to access timely primary care (including nights and weekends). How much is due to internal management and patient flow problems within the hospital? If your ER isn't crowded, what are they doing right? How are people getting appropriate community-based care?
  • The Centers for Medicare and Medicaid Services, the federal government's Medicare agency, introduced "never event" payment rules, meaning they won't pay for certain avoidable conditions such as wrong-site surgery or certain hospital-acquired infections.57Some states and private insurers are introducing similar policies. This isn't expected to radically change payments to hospitals in the early years, but it is designed to make hospitals take a hard look at how they can improve quality. How do hospitals in your community stack up? How have they responded to the new policy? Is your state requiring hospital to do more reporting on mistakes or hospital-acquired conditions including infections?
  • Many large employers have introduced workplace wellness and prevention programs. Are they working? Are they cost-effective? Do they discriminate against people who have chronic conditions?
  • Community health clinics have taken on an expanded role in covering the poor and the uninsured, and this will grow in the coming years. The new reform law includes major new funding for these clinics. Quality varies; some clinics are actually de facto medical homes, which do a good job of providing primary care, coordinating chronic disease, and linking patients to needed social services in the community. How do your local clinics stack up?58
  • High risk pools authorized and funded by the ACA are intended for people who have been denied health insurance coverage due to a pre-existing condition. This is a temporary measure until 2014 when health insurance exchanges will make it easier for individuals to buy coverage - insurers will no longer be able to deny coverage due to pre-existing conditions. Did your state have its own high-risk pool before health reform? Who is running the ACA-funded high risk pool (“pre-existing condition insurance plan,” or PCIP) – the state or HHS? How many people have enrolled? Why aren’t more eligible people enrolling in the program? Is the cost of the insurance too high?
  • More and more physicians across the country are changing to electronic health records, though the rate of uptake varies from region to region. Are physicians in your community using paper or electronic records? Are these physicians in single, double or large group practices? If they are not converting to electronic records, why not? If they have converted, how has it changed their practice?

ENDNOTES

1 Congressional Budget Office (2010). “Cost Estimate for H.R. 4872, Reconciliation Act of 2010 (Final Health Care Legislation): Table 4.” Congressional Budget Office Analysis. (www.cbo.gov/ftpdocs/113xx/doc11379/Manager'sAmendmenttoReconciliationProposal.pdf).

2 Congressional Budget Office (2010). “Cost Estimate for H.R. 4872, Reconciliation Act of 2010 (Final Health Care Legislation): Table 4.” Congressional Budget Office Analysis. (www.cbo.gov/ftpdocs/113xx/doc11379/Manager'sAmendmenttoReconciliationProposal.pdf).

3 Congressional Budget Office (2010). “Health Care.” (www.cbo.gov/publications/collections/health.cfm)

4 U.S. Census Bureau (2011). “Table HIB-6. Health Insurance Coverage Status and Type of Coverage By State – Persons Under 65: 1999 to 2010" (www.census.gov/hhes/www/hlthins/data/historical/HIB_tables.html)

5 Fronstin, Paul (2011). “Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 2011 Current Population Survey.” EBRI Issue Brief no. 362. Washington, DC: Employee Benefit Research Institute. p. 15. (.. www.ebri.org/pdf/briefspdf/EBRI_IB_09-2011_No362_Uninsured1.pdf

6 U.S. Census Bureau, Current Population Survey, 2011 Annual Social and Economic Supplement. “Table HI01. Health Insurance Coverage Status and Type of Coverage by Selected Characteristics: 2010, All Races.” (www.census.gov/hhes/www/cpstables/032011/health/h01_001.htm ).

7 Martin, Anne B., David Lassman, Benjamin Washington and others (2012). “Growth In US Health Spending Remained Slow In 2010: Health Share Of Gross Domestic Product Was Unchanged From 2009,” Health Affairs 31:1, January, Exhibit 4, p. 209. (www.healthaffairs.org)

8 CBO Director’s Blog. “CBO’s Preliminary Analysis of H.R. 2, the Repealing the Job-Killing Health Care Law Act” http://cboblog.cbo.gov/?p=1750.

9 David A. Squires (2011). “The U.S. Health System in Perspective: A Comparison of Twelve Industrialized Nations.” The Commonwealth Fund, July, p. 1: www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2011/Jul/1532_Squires_US_hlt_sys_comparison_12_nations_intl_brief_v2.pdf

10 Lawrence, D (2005). “Bridging the Quality Chasm,” in Building a Better Delivery System: A New Engineering/Health Care Partnership, Institute of Medicine. Washington D.C.: National Academies Press, 2005. 99-101. (http://books.nap.edu/openbook.php?record_id=11378&page=99)..

11 Office of the Press Secretary White House. “Remarks by the President and Vice President at Signing of the Health Insurance Reform Bill.” Whitehouse.gov. The White House, 23 Mar. 2010. Web. (http://www.whitehouse.gov/the-press-office/remarks-president-and-vice-president-signing-health-insurance-reform-bill).

12 Schoen, Cathy et al. (2008). In Chronic Condition: Experiences of Patients with Complex Health Care Needs, in Eight Countries, 2008. The Commonwealth Fund, Nov. 13. (www.commonwealthfund.org/publications/publications_show.htm?doc_id=726492).

13 Holahan, John, Bowen Garrett, Irene Headen, and Aaron Lucas. “Health Reform: The Cost of Failure.” The Robert Wood Johnson Foundation and The Urban Institute, 21 May 2009. (www.rwjf.org/files/research/costoffailure20090529.pdf) and Carpenter, Elizabeth; Axeen, Sarah. “The Cost of Doing Nothing.” The New America Foundation, 13 Nov. 2008. (www.newamerica.net/files/nafmigration/NAFCostofDoingNothing.pdf).

14 Nichols, Len; Axeen, Sarah. “Employer Health Costs in a Global Economy: A Competitive Disadvantage for U.S. Firms” New America Foundation policy paper. May 2008. (www.newamerica.net/publications/policy/employer_health_costs_global_economy ) and CED Research and Policy Committee (2007). "Quality, Affordable Health Care for All: Moving Beyond the Employer-Based Health-Insurance System." Committee for Economic Development. (http://www.ced.org/images/library/reports/health_care/report_healthcare07.pdf).

15 Kaiser Family Foundation (2012). Kaiser Health Tracking Poll – January 2012. www.kff.org/kaiserpolls/8274.cfm

16 Blendon, Robert J., and John M. Benson. "Public Opinion at the Time of the Vote on Health Care Reform." The New England Journal of Medicine (2010). Online. (healthcarereform.nejm.org/?p=3284&query=home).

17 Congressional Budget Office (2010). “Cost Estimate for H.R. 4872, Reconciliation Act of 2010 (Final Health Care Legislation): Table 4.” Congressional Budget Office Analysis. (www.cbo.gov/ftpdocs/113xx/doc11379/Manager'sAmendmenttoReconciliationProposal.pdf).

18 Ibid.

19 Hall, Mark.(2011) Urban Institute.

20 Rovner, Julie. "Republicans Spurn Once-Favored Health Mandate." Morning Edition. NPR. 15 Feb. 2010. Radio. (http://www.npr.org/templates/story/story.php?storyId=123670612).

21 "H.R. 4872, The Health Care and Education Reconciliation Act." 111th Cong. (enacted). Sec. 2303. (http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_bills&docid=f:h4872enr.txt.pdf).

22 "H.R. 3590, The Patient Protection and Affordable Care Act." 111th Cong. (enacted). Sec. 1311. (http://democrats.senate.gov/reform/patient-protection-affordable-care-act-as-passed.pdf).

23 Congressional Budget Office (2010). “Letter to Nancy Pelosi re estimate of the direct spending and revenue effects of the reconciliation proposal” Table 4. Estimated Effects of the Insurance Coverage Provisions of the Reconciliation Proposal Combined with H.R. 3590 as passed by the Senate. March 20. (http://www.cbo.gov/ftpdocs/113xx/doc11379/AmendReconProp.pdf )

24 "H.R. 3590, The Patient Protection and Affordable Care Act." 111th Cong. (enacted). Sec. 2704 and Sec. 2711-2712. (http://democrats.senate.gov/reform/patient-protection-affordable-care-act-as-passed.pdf).

25 H.R. 3590, The Patient Protection and Affordable Care Act." 111th Cong. (enacted). Sec. 2713 and Sec. 4104-4106. (http://democrats.senate.gov/reform/patient-protection-affordable-care-act-as-passed.pdf).

26 "H.R. 4872, The Health Care and Education Reconciliation Act." 111th Cong. (enacted). Sec. 1101. (http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_bills&docid=f:h4872enr.txt.pdf).

27 Bodenheimer, Thomas, Ellen Chen, and Heather D. Bennett. "Confronting The Growing Burden Of Chronic Disease: Can The U.S. Health Care Workforce Do The Job?" Health Affairs Vol. 28, No. 1 (2009): 64-74. (http://content.healthaffairs.org/cgi/content/abstract/28/1/64)

28 Mary E. Tinetti and Stephanie A. Studenski (2011). “Comparative Effectiveness Research and Patients with Multiple Chronic Conditions.” New England Journal of Medicine 364: 2478-2481, June 30. (www.nejm.org/doi/full/10.1056/NEJMp1100535)

29 Mechanic, Robert and Stuart Altman. "Medicare’s Opportunity to Encourage Innovation in Health Care Delivery." The New England Journal of Medicine (2010). Online. (http://healthcarereform.nejm.org/?p=3108).

30 "H.R. 3590, The Patient Protection and Affordable Care Act." 111th Cong. (enacted). Sec. 6301. (http://democrats.senate.gov/reform/patient-protection-affordable-care-act-as-passed.pdf.)

31 David A. Squires (2011). “The U.S. Health System in Perspective: A Comparison of Twelve Industrialized Nations.” The Commonwealth Fund, July, p. 1. www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2011/Jul/1532_Squires_US_hlt_sys_comparison_12_nations_intl_brief_v2.pdf

32 C. Schoen, R. Osborn, D. Squires, M. M. Doty, R. Pierson, and S. Applebaum, “How Health Insurance Design Affects Access to Care and Costs, by Income, in Eleven Countries,” Health Affairs Web First, Nov. 18, 2010; http://www.commonwealthfund.org/Content/Publications/In-the-Literature/2010/Nov/How-Health-Insurance-Design-Access-Care-Costs.aspx

33 D.R. Rittenhouse, et al. “Primary Care and Accountable Care — Two Essential Elements of Delivery-System Reform.” NEJM Perspective December 2009. http://healthpolicyandreform.nejm.org/?p=2205; and Aaron McKethan and Mark McClellan. “Moving From Volume-Driven Medicine Toward Accountable Care.” http://healthaffairs.org/blog/2009/08/20/moving-from-volume-driven-medicine-toward-accountable-care/

34 Centers for Disease Control and Prevention. Healthy Aging. (www.cdc.gov/chronicdisease/resources/publications/AAG/aging.htm)

35 Centers for Disease Control and Prevention. Chronic Disease Overview. (www.cdc.gov/nccdphp/overview.htm ).

36 CDC http://www.cdc.gov/chronicdisease/resources/publications/AAG/pdf/chronic.pdf.

37 Kennth E. Thorpe, Lydia L. Ogen and Katya Galactionova (2010). “Chronic Conditions Account For Rise In Medicare Spending From 1987 To 2006.” Health Affairs, April, p. 718. (www.healthaffairs.org)

38 Alliance for Health Reform/Commonwealth Fund briefing (2008) Primary Care Innovation: The Patient-Centered Medical Home. (http://www.allhealth.org/briefing_detail.asp?bi=137).

39 Johnson, Carla K. "Doctor Shortage? 28 States May Expand Nurses' Role." The Associated Press. Google, 14 Apr. 2010. Web. (www.google.com/hostednews/ap/article/ALeqM5jCB6VTbMN12zQSwafnZfBJovMseAD9F2CK880)..

40 IOM. “The Future of Nursing: Leading Change, Advancing Health.” http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx.

41 The Scan Foundation (2010). A Summary of the Patient Protection and Affordable Care Act (P.L. 111-148) and Modifications by the Health Care and Education Reconciliation Act of 2010 (H.R. 4872). (http://www.thescanfoundation.org/sites/default/files/TSF%20Policy%20Brief%20No.%20%202%20Mar%20%202010%20-%20Side-by-Side_0.pdf).

42 DesRoches, Catherine; Campbell, Eric; Rao Sowmya et al. (2008). Electronic health records in ambulatory care -- a national survey of physicians. New England Journal of Medicine; 359:50-60. (http://content.nejm.org/cgi/ijlink?linkType=ABST&journalCode=nejm&resid=359/1/50 ).

43 Chun-Ju Hsiao , et al.(2010). “Electronic Medical Record/Electronic Health Record Systems of Office-based Physicians: United States, 2009 and Preliminary 2010 State Estimates.” National Center for Health Statistics http://www.cdc.gov/nchs/data/hestat/emr_ehr_09/emr_ehr_09.htm

44 “HHS Secretary Kathleen Sebelius announces major progress in doctors, hospital use of health information technology,” Business Wire (February 17, 2012) http://www.businesswire.com/news/home/20120217005782/en/HHS-Secretary-Kathleen-Sebelius-announces-major-progress.

45 Ibid.

46 Orszag, Peter (2008). Evidence on the Costs and Benefits of Health Information Technology. Testimony before the Subcommittee on Health of the U.S. House Ways and Means Committee, July 24, p. 17. ( www.cbo.gov/ftpdocs/95xx/doc9572/07-24-HealthIT.pdf ).

47 Halamka, John D (2010). “Making The Most Of Federal Health Information Technology Regulations.” Health Affairs 29, No. 4, p. 596–600. (content.healthaffairs.org/cgi/content/abstract/29/4/596).

48 Section 4302. PPACA (http://thomas.loc.gov/cgi-bin/bdquery/z?d111:HR03590:@@@L&summ2=m&)

49 Trust for America’s Health (2010). “Summary and Progress of Key Prevention and Public Health Provisions” http://healthyamericans.org/assets/files/Summary%20and%20Progress%20of%20Key%20Prevention%20and%20PH%20Provisions.pdf.

50 Section 4304. PPACA (http://thomas.loc.gov/cgi-bin/bdquery/z?d111:HR03590:@@@L&summ2=m&)

51 United States. Cong. Senate. Senate Finance Committee. Financing Comprehensive Health Care Reform: Proposed Health System Savings and Revenue Options. S. Rept. 20 May 2009. (http://finance.senate.gov/download/?id=d8b0f79c-ea88-49cb-96f8-1d6cf6c5b577).

52 The National Commission on Fiscal Responsibility and Reform (2010). “The Moment of Truth.” http://www.fiscalcommission.gov/sites/fiscalcommission.gov/files/documents/TheMomentofTruth12_1_2010.pdf .

53 Dorn, Stan; Holahan, John (2008). Are We Heading Toward Socialized Medicine? Urban Institute, April 16. ( www.urban.org/publications/411648.html).

54 Baicker, Katherine; Chandra, Amitabh (2004). Medicare Spending, the Physician Workforce, and Beneficiaries Quality of Care. Health Affairs, W4.184. ( www.healthaffairs.org).

55 See PowerPoint presentation by Melinda Abrams at the Sept. 22, 2008, briefing cosponsored by the Alliance for Health Reform and The Commonwealth Fund, Primary Care Innovation: The Patient-Centered Medical Home, and other downloadable resources on this subject (www.allhealth.org/briefing_detail.asp?bi=137 ).

56 DoBias, Matthew (2009). CMS makes never event nonpayment rules official. Modern Healthcare, Jan. 15. (www.modernhealthcare.com/article/20090115/REG/301159955 ).

57 Alliance for Health Reform (2009) Community Health Centers: Their Post-Stimulus Role in Health Reform. (http://www.allhealth.org/briefing_detail.asp?bi=146).

 
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