Whatever the result on Tuesday, Obamacare will be with us, in one form or another. That was a clear takeaway from the annual Community Leadership Briefing convened by the Summa Health System last week.
David Gergen, of CNN, Harvard and former White Houses, said so.
So did Dr. Louis Sullivan, a former secretary of health and human services under George Bush the elder.
Listen to Thomas Strauss, the president and chief executive of Summa, and he appears determined to push forward with elements encouraged by the Affordable Care Act. That includes an ambitious accountable care organization, designed to link financially hospitals and physicians, providing incentives to achieve greater coordination in health care, putting quality ahead of volume.
Gergen and Sullivan cited the popular aspects of Obamacare, such as coverage for pre-existing conditions and children remaining on their parents’ insurance plan up to age 26. Yet there is something else that promises to endure — how the act seeks to curb the unaffordable trajectory of health-care costs, one projection calculating that if Medicare spending continues to climb at the pace of the past 40 years, it will consume all federal revenues by 2060.
One argument goes that the Affordable Care Act is the work of spendthrifts, recklessly expanding federal health coverage, throwing subsidies at the uninsured. Put aside that the Congressional Budget Office has concluded the new law will not add to the deficit, even result in a small savings. More revealing are the many experiments, pilots and the like in pursuit of cost-savings.
They are unproven, to be sure. Yet they remained, as other options for corralling costs proved politically untenable or unlikely to work.
Peter Orszag, a former budget chief at the Obama White House and now at Citigroup, has explained that there is an easy way to slow the rise of health costs: Slash deeply payments to doctors, hospitals and drugmakers, or implement direct rationing, just denying services to patients.
Neither is practical.
Why not put more responsibility on consumers to reduce their own health spending? As Orszag has noted, that may bring savings at the margin. So much of the cost involves a relatively small number of seriously ill patients, who follow the advice of their doctor, the expensive care rightly covered by insurance.
In an essay a year ago in Foreign Affairs, Orszag shared that the top 5 percent of Medicare beneficiaries ranked by cost account for 40 percent of Medicare spending, The top 25 percent account for more than 85 percent of total costs.
It may make sense to apply a means-test to Medicare. Yet to slow spending in a substantial way requires a gradual and profound change in the culture of health care.
That promises to be hard and complicated, to say the least. Some parts are inevitable, information technology, say, bringing together more accurate and timely information for providers about patients. Other parts are more explorations, and many are found in the Affordable Care Act.
There are the penalties for high rates of infections acquired in hospitals and high readmission rates of patients. An independent panel of medical experts, the Independent Payment Advisory Board, isn’t the threat critics paint. It would examine the Medicare payment system, looking to design incentives for quality over the volume of procedures.
The thinking follows the practical line drawn by Atul Gawande, a Boston surgeon writing in The New Yorker. He has brought attention to “hot spots,” those parts of a community where the highest health costs are clustered. He tells the story of Camden, N.J., mobilizing resources to attack the problem, the investment in care resulting in reduced costs.
Gawande relays how La Crosse, Wis., addressed the huge expense of end-of-life care. All patients of hospitals, nursing homes and assisted living facilities were asked a handful of questions concerning the care they were willing to endure, or the level of being alive they would tolerate.
A decade later, end-of-life costs in La Crosse were half the national average. Fewer days were spent in the hospital during the last six months of life, patients more alert to the distinction between prolonging life and having a better quality of life.
At the Summa community briefing, Thomas Strauss echoed all of this in his remarks. He cited the Monica Gardner Legacy Diabetes Ministry program taking aim at a “hot spot” in Akron. He reported the progress, 60 percent of the participants with lower blood pressure, lower blood glucose levels and narrower waistlines.
Summa has launched other experiments. Strauss pointed to the Center for Health Equity deploying resources to make care more accessible in underserved parts of the city.
This is what he means when he talks about no turning back from the Affordable Care Act. Beyond the many flaws, plus the hollow talk of a “government takeover,” the new law has a pragmatic core. If it extends health coverage to 30 million of the uninsured, it also extends an invitation to what works. It is a platform for devising something better.
Douglas is the Beacon Journal editorial page editor. He can be reached at 330-996-3514, or emailed at mdouglas@thebeaconjournal.com.
