My friend and former IBM colleague John Patrick posted a very good entry in his blog on the Affordable Care Act (ACA), aka Obamacare. As we all know, the ACA has had a rough start. In his entry, John asks two basic questions: do we need the ACA?; and, should it be repealed?
John has always been a pioneer in embracing new technologies. He understood the power of the Internet very early on and worked tirelessly to get IBM involved. Together, we organized IBM’s Internet Division in the mid-1990s and continued to work closely until his retirement from IBM in 2001. He was one of the first people I knew who had a blog, - which is still going strong after all these years, - and was a big influence in my decision to start my own blog in May of 2005.
Do we need the ACA or something like it? John points out that “The United States is the only developed country in the world that does not have universal healthcare, meaning that all citizens have healthcare insurance.” Different countries have developed universal health care along different models. The UK has a single payer system. Germany’s is based on over 200 payers. Canada’s is operated by its 13 provinces.
He cites a 2002 study by the Institute of Medicine, Care Without Coverage: Too Little, Too Late. At the time, roughly 30 million working-age Americans, about one in seven, did not have have health insurance, not including the roughly 10 million uninsured children or anyone over 65 covered by Medicare. The number is considerably higher today. “The main findings, extrapolated to today, show that 25,000-50,000 people die each year because they do not have healthcare insurance. A person with a serious cancer that was not diagnosed until the pain was significant can go to the ER and then go home with pain killers ultimately to die.”
“One reason for the unending debates about healthcare is that, as a country, we have not come to grips with the basic question of whether citizens have a right to healthcare,” he writes. Is it OK for tens of thousands to die every year because they lack healthcare insurance? Do all American citizens have a right to healthcare, just like they have a right to vote, free public education and police protection? “This is a moral question and I have not heard any politicians from either party talk about the subject.”
Next, John asks if given its launch issues and overall complexity, we would be better off repealing the ACA and starting all over?
He references a recent article by professor John McDonough, director of Harvard’s Center for Public Health Leadership. Professor McDonough believes that even though it will not take effect until 2014, the ACA law has already brought the biggest changes in the history of federal health policy-making.
“I have been watching US federal and state health policy closely since 1985,” he writes. “Without reservation, this is the most dynamic period I have seen, at least on par with the creation of Medicare and Medicaid in the late 1960s, and so much more expansive. Much has been accomplished already, and much remains to be done; some elements have been repealed or delayed. Overall, the scope and pace of change in the past 3.5 years is astonishing.”
“The movement toward accountable care and away from fee-for-service is proceeding,” he adds. “On many of these reforms, flaws and shortcomings in the statutory language of the ACA should drive Congress to continuously assess and modify the law in a common practice that I call continuous policy improvement. Unfortunately, the intensely partisan divide over the ACA in Washington, DC, has prevented Congress from fulfilling its normal function to correct, amend, and improve complex laws such as the ACA. . . We can only hope that Congress will soon be able to play its essential role in overseeing [and] improving the law as implementation unfolds.”
Another reason for supporting the ACA is the economic transition the country is going through, says NY Times columnist Tom Friedman in Why I (Still) Support Obamacare. Global competition continues to drive companies to aggressively focus on productivity, leveraging IT-based innovations to get their work done with fewer employees. And government agencies will continue to shed jobs given the pressures they face to reduce costs and slim down. Many jobs with decent wages and benefits have disappeared and no one can tell if or when they are coming back.
As a result, sustaining a middle-class lifestyle will require rethinking the concept of employment compared with the traditional job with benefits and a well-grooved career path. We need to become a much more entrepreneurial society. Large numbers of people will have to invent their own jobs and consider more nontraditional forms of work “where you draw on all kinds of assets and skills to generate income,” writes Friedman.
“In the end, this transition we’re going through could prove more exciting than people think, but right now asking large numbers of people to go from being an employee to a work entrepreneur feels scary and uncertain. Having a national health care safety net under the vast majority of Americans - to ease and enable people to make this transition - is both morally right and in the interest of everyone who wants a stable society.”
What went wrong with the rollout of HealthCare.gov? It’s difficult to assess what really happened while still in the eye of the storm, but one of the best early articles I’ve read on the subject is by oncologist Ezekiel Emanuel, a vice provost and professor at the University of Pennsylvania and a former White House advisor on health policy. He attributes the problems to three big mistakes.
First, the administration did not want to release detail regulations and specifications on the exchange while in the middle of the 2012 election campaign in order to avoid political controversies. “This may have been a smart political move in the short term, but it left the administration scrambling to get the IT infrastructure together in time, robbing it of an opportunity to adequately consult with independent experts, test the site and fix any problems before it opened to the public.”
Second, in a project of this complexity and magnitude you need a very strong general manager who understands both the health and IT issues involved. Instead, the Center for Medicare and Medicaid Services was in charge of managing the project. The agency has little experience in developing such a complex Web site. And, no one of sufficient stature and expertise had overall responsibility for the project.
Finally, HealthCare.gov should have taken advantage of the experiences with other health insurance exchanges, such as the Massachusetts Health Connector and eHealth that have been operating for years, or the various states like California, Connecticut and Kentucky that had already been building and testing their exchanges. “It does not appear that the Centers for Medicare and Medicaid Services or its contractors spent much time reviewing these models and adopting best practices.”
In the article, Professor Emanuel recommends a number of steps to fix the ACA, starting with the appointment of an independent chief executive for the federal exchange. “We need someone who can not just begin the repair process, but also run and refine the exchange’s operations for at least the next two years. This C.E.O. should meet one on one with the president every week to ensure he or she has full authority to carry out the job. The candidate should have management experience, knowledge of how both the government and health insurance industry work, and at least some familiarity with IT systems.”
I think that most people who support the concept of universal health care in the first place believe that we should fix the ACA rather than starting all over. “While there is plenty of room for improvement, there are some excellent programs in the ACA that are well underway and that are improving patient safety and quality and reducing the cost of healthcare,” concludes John Patrick in his blog. “Repealing [the ACA] may be throwing out the baby with the bath water.”