Monday, October 7, 2013

Walk with Me, We've Got a lot to Talk About

Several important developments in health care have taken place in the U.S. within the past week as the stage is being set for the implementation of the Affordable Care Act (ACA) at the start of the new year. On October 1, our nation witnessed the red carpet rollout of the state-based health insurance marketplace, which marked the beginning of open enrollment, a period during which people on the market for insurance coverage- either previously uninsured or looking to change plans in hopes of securing a better deal- can shop for health insurance using their state's database of coverage options (a period which runs through March 2014). This innovation in the process through which we purchase health insurance, allowing for a choice of plans and competition between payers (which as we will see tends to drive prices down), is vital for the progression of our system toward a more equitable model; one that has at its core what Dr. Donald Berwick would call the Triple Aim- the goal of improving population health while increasing quality of care and reducing costs.

"Improving health and care quality while reducing/containing costs."

As Dr. Berwick and the Institute for Healthcare Improvement (IHI), the Cambridge-based think tank that he helped found, would stress, the three principles consisting of population health, quality of care, and cost, symbolized by the vertices of the triangle, need not be at odds with one another. To take this point (ha-ha!) further, the aims are connected with bisecting lines, which meet in the center at a single intersection that signifies the common ground between the three aims. Bearing resemblance to a target, by no means a coincidence, we are able to utilize this comprehensive metric to set our standard for success with any reform or quality improvement effort moving forward.

In addition to the innovations we're experiencing with the newly formed insurance exchanges, we’re also seeing more people eligible for health insurance coverage than ever before, though we'll still be left with some ways to go to attain universal coverage. As the numbers would suggest, an additional 16 million will likely remain uninsured after the expansion, meaning the country will lie at about 95% coverage. That said, some states are getting close to full coverage with Massachusetts leading the way at 98% (fellow northern states Vermont, Minnesota and Wisconsin are also above 90%).

Data based on 2009 U.S. Census. Thanks to Wikipedia for use of their map and legend!

In later posts, I’ll discuss how other countries have performed with relation to universal health care - Spoiler alert: we’ll see that the U.S. isn’t exactly pioneering in this regard.

It truly is an exciting time, and yet, it is also a time of mass confusion and near hysteria- see any of the many news articles on the government shutdown. As much remains uncertain, there is a tendency to fear the worst. But, we must refrain from getting caught up in the hoopla and trust in the process that has gotten us to this point. The ACA was written into law over three-and-a-half years ago having passed through the House and Senate and finally receiving the signature of President Obama, showing us that the consensus amongst legislators at that time was that this bill has a potential for doing good. Now when we open the paper (or pull up our favorite news vendor's website), we're liable to see chatter about Federal budget constraints and the debt ceiling- money, money, money! These are real concerns for sure and there is some element of uncertainty to all of this. But, we must keep in mind what this is all for: that these types of legislation impact the lives of real people. 

I think it’s fair to say that health care reform is a complex beast. This is true everywhere in the world, but especially true in America where our melting pot of a society seeks care from an intricate network of providers and payers who sometimes cover the cost of procedures, and other times do not. This system leaves many not being able to afford the care that they seek and provokes a psychological stress unseen anywhere else in the developed world when one is left to decide between seeking or avoiding care for fear of going bankrupt. To make matters worse, our health insurance has long been tied to our employer, so that if we happen to lose employment, we also lose coverage (affordable coverage, that is, since we can all agree that COBRA is not!)...Only in America, right??

Far from profound, the expansion no doubt will have the greatest impact on those who had been previously denied or unable to afford coverage and now are eligible to have their care at least partially (at most entirely) subsidized. This is a monumental step toward a more equitable system: one where the rich, the poor, the black, the white, the old, the young, (male, female, third sex, heterosexual, homosexual, metrosexual, whatever!) from state to state have equal access to care of quality and reasonable cost - a system that truly nurtures the growth of healthier communities. That’s the goal. That’s the culmination of the Triple Aim - or should I say Aim'en!

I’ll end end with a video that serves as a great introduction into this realm of thinking, constituting what we'll call the "Leading (w)Edge" philosophy (if you're already familiar, feel free to brush up!). Professor John McDonough of Harvard School of Public Health, a key player in the drafting of the ACA, hosts the aforementioned Dr. Donald Berwick, a pediatrician by training, founder and President Emeritus of IHI, most recently having served a 17-month recess appointment as Administrator of the Centers for Medicare and Medicaid Services (CMS) in Washington, D.C, which ended in December 2011, for an enlightening discussion on healthcare reform and more. At present, Dr. Berwick is contemplating a position in public office, having recently thrown his hat into the ring for a possible run for Governor of Massachusetts in 2014. If that’s the case and the Triple Aim has taught us anything, you may want to seriously consider giving him your vote. Please, take a look.

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