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Reinventing American Health Care: How the Affordable Care Act Will Improve Our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System

2016; Duke University Press; Volume: 42; Issue: 1 Linguagem: Inglês

10.1215/03616878-3702818

1527-1927

William Brandon,

Information Systems Theories and Implementation

The florid title with its cornucopia of adverbs and adjectives suggests that this book is a guide to profound changes in the US health care system that will be produced by the Patient Protection and Affordable Care Act of 2010 (ACA). The prospect of a bold, systematic effort to look beyond the politics of enacting the ACA, the vicissitudes of implementation, and the fragmented projections of specific, already visible developments seemingly generated by the ACA (e.g., greatly increased merger and acquisition activity) to discern the overall shape of the organization, delivery, and financing of health care in the post-ACA era is exciting. But this book by one of the thought leaders in American health care and academic medicine—and an architect of the ACA—attempts to accomplish two other tasks on the way to that desideratum and, therefore, fails to provide the systematic exposition of the new health care system that seems to be promised by its title.The reader of “Acknowledgments” (xiii) learns that the book also intends to fulfill a perceived need for an introduction to the US health care system. Emanuel explains the origin of this objective by his frustration in trying to bring a New York Times correspondent with a foreign policy background reassigned to cover health care in 2011 “up to speed” on the US health care system in a one-hour meeting. There are already numerous volumes used in professional masters’ courses that explain the US health care system; Emanuel's contribution to this expanding bookshelf—the first four chapters—is unexceptional.The second focus of the book is health reform. Six chapters (5–10) explain the ACA (chapters 8 and 9) after providing an account of the long history of health reform in America (chapter 5), the enactment of the ACA (chapter 6), the early stages of implementation1 (chapter 10), and the 2012 Supreme Court decision (chapter 7) that upheld the individual mandate and gave states a choice about expanding Medicaid. Because Emanuel's brother Rahm was President Obama's chief of staff at the time and Emanuel himself worked closely with the White House to fashion the health reform legislation, it would be reasonable to expect his account of enactment to provide some juicy insider perspectives on the politics and personalities. Although this reviewer found bits of chapter 6, “Enacting the Affordable Care Act,” interesting, most of it was already familiar from contemporary journalism and Paul Starr's excellent Remedy and Reaction (2011). Chapter 10, “ACA Implementation Problems,” did inform me about important developments that I had not absorbed from contemporary media, which greatly reduced coverage of health care after the ACA was signed.Particularly informative is Emanuel's discussion of the debates between those pushing for the appointment of an experienced manager/“CEO” to take control of implementation and those who opposed creating a new lightning rod to attract criticism. Emanuel lined up with those wanting to hire an outside CEO to galvanize action across the federal agencies involved in implementation. Outsiders contributed to the debate as well: Harvard economist and health services researcher David Cutler sent an “unsolicited memo” advocating for a strong and empowered manager. In the end, the chief administration figures pushing for a seasoned manager (National Economic Council Director Larry Summers, Office of Management and Budget Director Peter Orszag, and Rahm Emanuel himself) left Washington. Thus, the White House policy analysts led by Nancy-Ann DeParle, who had devoted so much time and energy to securing passage of the Act, oversaw implementation.If the introduction of the health care system is humdrum and the enactment of the ACA is already an oft-told tale with little new added except for the account of the struggle over control of implementation, it is in the last three chapters of some fifty pages where the venturesome thinker begins to outline his original ideas and thereby begins to redeem the promise of his title. Emanuel, after all, is the brave soul who prophesied the end of health insurance companies (Emanuel and Liebman 2012), advocated for reducing the time spent training physicians (Emanuel and Fuchs 2012), and publically questioned investments in technology by some in the nation's most esteemed health care systems (Emanuel and Pearson 2012). In chapter 12 Emanuel explains needed changes in the health reform legislation and its implementation (ACA 2.0 replacing ACA 1.0), and in chapter 13 he dons John Naisbitt's futurist mantle (1982) by making bold, precise predictions. What makes Emanuel's outline of six “megatrends” so appealing is his ability to tie them together systemically.The six megatrends that Emanuel sees as resulting from the ACA are:■ Insurance companies will either become health care providers (employing or contracting for the care of their insured population) or evolve into health care consultant and support firms selling analytical, actuarial, and management skills to Accountable Care Organizations (ACOs) and integrated hospital systems. The ACOs and hospital systems themselves will have evolved to combine both the health insurance and care-providing functions. By offering a readily accessible marketplace where managed care plans can transact directly with individual consumers, the health insurance exchanges fostered by the ACA generate this inviting evolutionary path for ACOs and other integrated health care systems. He expects this evolution to be realized by 2025.■ An intense focus (“VIP care”) on the patients with chronic conditions and mental illness, the source of the greatest health care costs, will reduce annual health care expenses and improve care. Better tertiary prevention will improve outcomes for those with chronic conditions. Integration of mental health care into primary care will insure adequate care for patients with mental illness and finally achieve parity in attention and resources between physical and mental health. Tertiary prevention by mainstream “early majority” adopters will cut “10 to 20 percent of overall health care spending” by 2020 (325–26). Expanded mental health treatment based on a primary care model will be achieved over the decade of the 2020s, but Emanuel provides no estimate of the reduction in health care cost increases due to providing better mental health care.■ Over one thousand of some five thousand acute general hospitals will close, due to the improved tertiary care mentioned above, home visits by an expanded multi-profession health care workforce, the emergence of digital medicine that can monitor patients in their natural lives outside of health care settings, and the improved quality of hospital care stemming from the ACA's penalties for excessive readmissions and hospital-acquired infections. Emanuel predicts (“conservatively”) that the growing importance of these factors will lead to the closure of one thousand hospitals by 2020.■ Another mainstay of the US health care system—employer-sponsored health insurance, which is the source of financial access to health care for more than half of the current population—will collapse. This revolution will occur because both private exchanges and the ACA-mandated health insurance marketplaces bring individuals seeking coverage together in digital touch with insurance companies turned health care providers and competing provider-based organizations seeking prepayment (see first bullet above), thereby rendering the employer role otiose. He predicts that by 2025 less than one-fifth of private sector workers will have insurance provided by employers; government workers will take longer to wean off traditional coverage. Large employers will redirect expenditures for health benefits to defined contributions that enable workers to buy insurance on the exchanges and to higher wages and salaries. Some will calculate that paying the penalty for failing to provide insurance is considerably cheaper than providing insurance; their employees will be eligible for federal subsidies in the health insurance marketplaces unless family incomes exceed 400 percent of the federal poverty level. These predictions are buttressed by the “Cadillac” tax that negates the tax subsidies for the purchase of expensive employer-sponsored insurance. Because this tax is not indexed to inflation, it will quickly erode the incentive for middle-class employees to demand generous employment-provided coverage. Moreover, employers with fewer than fifty employees are not required to provide insurance; therefore, small employers currently offering coverage will use their health insurance expenditures to pay higher salaries, because the ACA enables individuals to easily shop for their own insurance. Consequently, Emanuel believes, the small business exchanges envisioned by the ACA are a nonstarter.■ By 2020 health care spending will increase at GDP+0 percent (i.e., grow at the same rate as overall national income; gross domestic product, GDP).2 Such a growth rate would be a significant achievement, because since 1975 health care spending has grown by an average that is 2 percent greater than GDP growth. (Not included in GDP+0 percent is allowance for population increase, which will make the actual health care costs rise a bit faster than GDP.) A number of factors, all explicit or implicit in the above bullets, will accomplish this remarkable feat. Greatly increased consumer sensitivity to costs to be accomplished by establishing a cash nexus between individuals and insurers seems to be the underlying impetus implicitly posited in most aspects of Emanuel's analysis. Specific sources of cost-control include the emphasis on tertiary prevention in chronic illness and mental health parity integrated into primary care practices, the rise of digital medicine and decreased hospitalization, and the many payment reforms encouraged by the ACA, including bundling and competitive bidding. Together, these effects of the ACA will generate a culture of conservative spending by providers, payers, and patients.■ Finally, following an indictment of medical education (which “remains firmly in 1910” [339]), this medical educator prophesies a revolution by 2025: shortening medical school to three years with only one year of preclinical study and shorter residency and specialty fellowship training; de-emphasis on research; at least half of all medical training outside of hospitals (by mid-2020s), and much of that training where patients are domiciled (institutions as well as private homes); inclusion of students studying many different health professions in medical school classes, which will build the foundation for multidisciplinary health care delivery teams—the provider units of the future; inclusion of skills in team building and management that will require new multidisciplinary medical school faculty; much greater focus on population health in all levels of medical training; “training in digital medicine . . . including using electronic health records, . . . analytics, . . . decision supports, engaging in electronic communications with patients and their caregivers, . . . constant monitoring of quality, . . . new sensors and digital monitoring devices, telemedicine, and how to integrate them effectively and efficiently into the care of patients” (343).The megatrends are interconnected and mutually reinforcing. Thus, development of ACOs that directly market coverage on health insurance exchanges and the end of health insurance companies as we know them today illustrates the interaction of health care financing and its organization. The virtual demise of employer-sponsored health insurance means that individuals will make personal purchasing decisions about health coverage offered on the ACA health insurance marketplaces or private exchanges. Financial imperatives will foster improvements in the delivery of chronic and mental health care in information technology-rich environments in home and community settings. The success of these changes will make one-fifth or more of hospitals redundant as improved care focuses on treating patients at home or in other settings. All these achievements together will produce strong pressure to restructure the health care workforce by emphasizing team delivery of health care. Health care delivery will be undergirded by digital connectivity and the full armamentarium of high-tech monitoring and diagnostic devices. The needs of this new era in health care delivery, Emanuel maintains, will demand radical changes in the education of physicians and other health professionals on the health care team.Any assessment of this bold agenda for change is beyond the scope of a review. But one note of admiration and another of doubt are appropriate. This supporter of the ACA has always regarded the ACA as focused largely on securing financial access to health care for more Americans. The ACA's provisions for reforming health care in the United States seem largely confined to modest financial carrots and sticks and a few gentle nudges and shoves to the delivery system. The first five of Emanuel's “megatrends,” however, constitute a plausible case by one of its architects for believing that the ACA will accomplish fundamental change in the structure and delivery of care, not only in its financing. The sixth megatrend appears to this skeptic to fall into the category of wishful thinking, unconnected to the ACA. Of course, reform of medical education ought logically to occur in light of the demands of a new epoch in health care structure, delivery, and finance, but what could possibly induce these changes, given the insulation of medical schools and the engrained traditions of academic medicine?One seemingly small technical detail, which the book does not mention, does seem to bring into question the underlying mechanism of increasing price sensitivity on which the megatrend projections are based. Will individual consumers of insurance and care search for low prices in a context of increased price competition among health providers, insurers, and suppliers that induces them to bargain down profit margins? In the ACA health insurance marketplaces, the subsidies for the purchase of the second least expensive silver plan are indexed to the consumer price index (beginning in 2019), and patient cost-sharing subsidies must keep pace with the rise of the federal poverty level (which is also indexed). Unless these provisions are changed, why would individuals buying insurance in the ACA marketplaces or seeking care after securing coverage or, for example, a surgeon ordering a hip implant (included in the hospital bill, not the charge for medical service) seek the lowest cost or even the most cost-effective intervention instead of buying the “best” without regard to cost? Without the impetus to economize, many of the megatrends are likely to stall, or at least fail to transform the entire system in the near future.Of course, the fact that the federal government will pick up the tab for premium and patient cost-sharing increases for those below 400 percent and 250 percent of the federal poverty level, respectively, who purchase coverage on the ACA health marketplaces should give those exchanges a great advantage over other ways to secure financial access to health care (aside from Medicare and Medicaid). Emanuel will see this effect as one more nail in the coffin of employer-sponsored insurance. Over the long term, this dynamic might cause the health care system to approximate a single-payer system as more and more individuals buy subsidized insurance on the ACA marketplaces. But can the political system tolerate the federal financial bleeding while we all wait for the long term to arrive, especially if cost increases are not held to GDP+0 percent?When so many of its supporters look backward to see the ACA as the culmination of—or at least a major step in—a hundred-year struggle to broaden access to health care, and its opponents seek to find and capitalize on every evident flaw, Emanuel does provide a service in restoring our focus on the future. He believes that, despite its imperfections and the botched implementation, the ACA is quite literally an epoch-making event of the magnitude of the Flexnerian revolution, which ushered in modern medical practice as we know it today, and the passage of Medicare and Medicaid, which brought significant federal funding into the financing of health care that led to fundamental restructuring of the health care system. Over time, the short-term implementation mistakes will be eclipsed, he writes (347), by this “world historical achievement, even more important for the United States than Social Security and Medicare have been. . . . Barack Obama will be viewed more like Harry Truman, . . . with increasing respect.”In his last pages, Emanuel (347) specifies what he believes is the most important aspect of the “transformation of that entire American health care system [that the] ACA is stimulating.” Through its focus on value and efficiency, the ACA will finally reign in disproportionate increases in health care costs (above the GDP+0 percent formula). That “transformative impact,” which will rest on changes in patient care that will become evident by 2020, will “save the United States from fiscal calamity” and free up resources for such other pressing societal needs as infrastructure, early childhood education, scientific research, etc. (348–49). However, the full range of the changes triggered by the ACA will take a decade to emerge. Thus, not only is this ACA true-believer at odds with its opponents, he also parts company with most knowledgeable supporters of the legislation. Many of us view the ACA as ameliorative for all its flaws, but far from an epoch-making revolution.