News

The Arizona Medicaid program has been much in the news lately for its decisions to deny Medicaid coverage for certain transplants. The state has variously argued several things about these decisions. First, that these are evidence based decisions; that is, that the transplants were denied because the research shows that they don’t actually work. But, when challenged by transplant surgeons and others, the state has given other reasons for their denial, with cost being at the top of the list.

How ironic that during the debate on health care reform, the threat of rationing health care was used by opponents as a reason to oppose the Affordable Care, and here is a state with leadership that strongly opposed the Affordable Care Act but that are implementing rationing their own way.

To many health policy ethicists/analysts, the idea of explicit rationing of health care has much conceptual appeal. The idea is that we don’t have enough resources to pay for all the things we want as a society and therefore, we should choose what health care services to cover based on a transparent public process that takes into account both medical evidence and public preferences. Certainly, other countries with national systems and national health policy have made these kinds of choices, at least to some degree.

Some in Congress used Don Berwick’s favorable comments about the British Health Care system as a reason to oppose his appointment to head CMS because they noted that the British system rations health care. Indeed, in Great Britain, there are some explicit discussions about trade- offs in coverage and a valuation of the benefit of certain services in terms of “Quality of Life Years”obtained.

But, the practice of explicit health care rationing – vs. the more implicit approach we take in the U.S. today: rationing through price and lack of any coverage for broad segments of the population – is far more difficult than the theory. When one looks more deeply at the British system, the limits of rationing are apparent. But, perhaps, the best example of this issue in the U.S. is what happened many years ago in Oregon.

In 1987, Oregon had its own transplant controversy in the Medicaid program. At the time, the state denied coverage for leukemia treatment for a child. A physician, John Kitzhaber, was head of the Oregon legislature at the time and rather than pushing through support for the transplant coverage, he argued that with so many people uninsured, it was unfair and unethical to pay for a few high priced services for some but leave many without even basic care. Thus ensued a long path that resulted in the passage of the Oregon Health Plan, which was implemented in 1994 and supposed to be an explicit form of health care rationing where all procedures would be arrayed on a list based on value and a line drawn at a certain point based on the state resources available for the Medicaid program.

As chronicled in a terrific article written in 2001 for the Canadian Medical Association, Jon Oberlander and colleagues described the reality of what happened in Oregon and noted that it was far different from what the framers of the OHP originally envisioned. Indeed, they concluded that the system in Oregon actually excluded very few services and as a result, saved very little money (in fact, transplant coverage was actually expanded under the program). For those services that were excluded, the list was circumvented by physicians on a fairly routine basis as they found ways to get those services covered for their patients; and over time, the list was less and less reflective of objective, scientific theory and very much influenced by interest-group pressure.

Arizona’s approach today is essentially rationing by price: picking high ticket procedures and then looking for the evidence to support their exclusion from coverage. This approach undermines a legitimate public debate.

But, Oregon demonstrates that even when we try a transparent process to this issue, it, too, has difficulty being true to the conceptual framework it is based on. In Oregon’s case, the plan actually became more about expanding coverage than about choosing which resources to use.

It would be ideal if we could ask how much medical care we can afford and who should pay – and doing it thoughtfully, comprehensively, and in the full light of day. Arizona’s approach certainly doesn’t do that. While Oregon’s experience might say that we can’t get there, they tried and had a rich public debate as part of the process. It would be better if Arizona could at least have an honest and open approach to what they are doing.

One of the big issues that prompted the passage of health reform last year was the 39 percent rate increase proposed by Anthem California for the individual market. That action both strengthened the will of the Democrats to enact health care reform and provided a clear cut talking point about the need for reform. As a result, one of the provisions included in the reform law was that health insurance premiums could not increase at “unreasonable rates”.

Initially, the proposal was for there to be some federal oversight in health insurance rate increase requests. A clear cut federal process was not included in the Affordable Care Act. Rather, this issue was left to the states with some federal oversight.

For almost a year, people have been asking for a definition of “unreasonable” and what process would be used to determine what it. On December 21, the U.S. Department of Health and Human Services (HHS) issued rules to answer that question. Specifically, as noted in this press release, in 2011, the answer to the question is 10 percent. After that time, the specific state rate increases will be based on state specific information and trends.

Time will tell how this rule gets implemented and whether it actually provides any relief for consumers, but it seems quite a stretch to think that this rule will do much to stabilize the market and make health care more affordable.

The immediate critique from the insurance industry was that this rule does nothing to deal with the underlying causes of increases in health care costs: provider prices and the use of services. And, while it is easier to put pressure on health plans to get them to try and deal with these issues, there are also things in the Affordable Care Act that could make it more difficult for health plans (I am still a skeptic on the concept of Accountable Care Organizations).

And, of course, we haven’t yet heard from state insurance commissioners about how they will handle the administration of this rule and whether they have the resources to review all premiums that would fall into this category – even with the extra funds provided under the ACA.

HHS notes that they will take over this function for any state insurance office that can’t do what is required. But, HHS is having its own challenges in getting funding from the current Congress, much less the new Congress – many members of which ran on a platform to repeal the ACA.

Finally, it strikes me that this rule is rife for a “playing to the test” strategy. Let’s see how many 9.9 percent rate increases go through next year and/or how many benefit changes occur to justify higher rates.

The 10 percent rate increase concept is, of course, very easy for consumers to understand. It has the virtue of enabling the administration to describe something about the Affordable Care Act that is easy to grasp and appealing to individuals. The same can’t be said about many other provisions of the Affordable Care Act, which are quite technical. In general, Congress and the administration have done a poor job communicating the benefits of health care reform to consumers. This piece could improve the administration’s success at communications.

The concept of a strong regulatory structure to oversee the insurance industry is a good one. It is necessary for confidence in the industry and for ensuring a level playing field for competition. And, of course, it is essential for ensuring that the core components of health care insurance expansion are implemented in compliance with the law and fairly at the state level. The idea of setting a single, specific number and declaring that anything that exceeds that is potentially considered “unreasonable” may be good politics but I am less certain it is good policy.

Much has been written this past week about the Virginia federal court decision about the constitutionality of the Affordable Care Act. While many have described the decision as politically motivated and delved into the politics of the various judges who have ruled or are about to rule on the Affordable Care Act, the more interesting question is: What is likely to happen at the Supreme Court level and what could happen to the Affordable Care Act based on that likely outcome?

Jason Mazzone had an interesting opinion piece in the New York Times interpreting the Virginia court’s decision. In his December 17 piece, he comments on the distinction between Congress regulating activity vs. inactivity, and asserts that the Virginia court made a credible case for its decision. I am not an attorney and can’t comment on the merits of his argument. But he certainly believes that this opinion could well be upheld by the Supreme Court.

Linda Greenhouse, the Supreme Court reporter for the New York Times, gives a much more attenuated interpretation of Judge Henry Hudson’s decision in her December 16 opinion piece. Regardless of the merits of his reasoning, if his opinion holds, what will that do to the law?

Well, first and foremost, the Virginia decision was actually more narrowly constructed than some media reports would lead one to believe – in two ways: first it only challenged the part of the law that deals with the individual mandate. Even though Congress did not include a severability provision with regard to this part of the law, the court decision was limited to the provision that requires people to carry health coverage or pay a fine. The Virginia court ruled that this provision both went beyond the Commerce Clause and that the fine was not a tax but rather, a penalty. The decision did not, however, invalidate any other parts of the law and it did not grant a stay of implementation of the law (in large part because the provision that would be invalidated by this ruling doesn’t go into effect until 2014). So, based on this ruling, the implementation of the Affordable Care Act will proceed apace while the ruling is appealed in the courts.

But, what would this decision mean for the law should it ultimately be upheld by the Supreme Court?  That is a complex question. The problem with invalidating the individual mandate is that there are many other provisions – let stand by the Virginia court – that are popular and integrally tied to the mandate. These include prohibitions on exclusions for pre-existing conditions, requirements for guaranteed issue, prohibitions on rescissions, and requirements to enable children up to 26 to stay on parents’ policies. Adverse selection is a serious problem with these parts of the law if they are not tied to some provision that ensures all (or, at least, most) people have health insurance.

So, what could Congress do that preserves these insurance-related provisions of the Affordable Care Act in the absence of an individual mandate?  Those who advocate for a single payer system will correctly note that this problem would have been avoided had Congress passed and the President signed a bill that worked entirely through the tax system, similar to the Canadian health system. But, the reality is that the votes were never there for this system and they are less there now with the change in Congress.

So, if there is a negative ruling in the Supreme Court, is there a feasible political alternative?   There might well be – one that was proposed during the original reform debate. In that debate, some advocated that instead of a mandate there should be a market based incentive system designed somewhat akin to Medicare Part B: a graduated rate depending on how early you get in. That is, health insurance would be cheaper if you signed up when you are relatively young and healthy than if you waited until you were older or sick. Among other economists, Mark Pauley recommended that approach (along with some other features) in his February 2010 perspective in the New England Journal of Medicine. And, that concept is one that is more likely to appeal to the new Congress – at least after much of the hardnosed “repeal and replace” rhetoric has passed. And, it is an approach that would save the fundamental principles of health reform through a different avenue. The mandate may ultimately prevail in the courts. But, if it doesn’t, it is well to keep in mind that all may not be lost.

In 2007, the COURAGE trial (aka: Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation –a mouthful!) results were reported in the New England Journal of Medicine. This study concluded that for those with stable coronary artery disease, the insertion of stents was no better than medication and lifestyle changes at preventing future heart attacks or strokes, nor did it extend life. There were different side effects from each approach but clinically, this trial supports the concept that the choice of treatment ought to be based on patient preferences unless there were unique clinical factors present. The COURAGE trial results were widely publicized and use rates of these procedures have declined overall since then.

Given all the evidence around treatment of patients with stable coronary artery disease, it was shocking to read a particular story about cardiac treatment as reported in the Dec 6, 2010 New York Times. The New York Times article is stunning in its depiction of some core issues about why US health care spending is high and how incentives in the current system can compromise patient care.

The article is about Dr. Midei, a Baltimore, Maryland cardiologist, a highly productive cardiologist. As an example of his productivity: the New York Times reported that on one particular day, Dr Midei inserted  cardiac stents in 30 different patients!  And, he was richly rewarded for this level of surgical intervention. In addition, of course, to obtaining a very high income (millions) as a result of all of these procedures, he was also courted and rewarded with perks and bonuses by Abbott Laboratories, the maker of the stents. The Centers for Medicaid and Medicare Services (CMS) has been investigating Dr Midei and has concluded that over a two year period he may have inserted almost 600 stents in Medicare patients that were medically unnecessary.  Dr Midei’s hospital, St Joseph, was accused of providing kickbacks in exchange for patients (each procedure can bring $10,000 in revenue to the hospital) and paid a fine to CMS of $22 million and let hundreds of patients know that they may have had stents inserted that they did not need. Many of these patients are now suing Dr. Midei. And even after all of these issues came to light, Abbot Laboratories put Dr. Midei on staff as a consultant in return for all the “help” he had provided to them over the years.

What an amazing illustration of many of the issues in the health care system today! Dr. Midei was not a fly by night doctor. He was trained at Johns Hopkins and considered a “star” in the Baltimore market.

This is clearly an illustration of the perversity of the incentives in the system at many levels. In fee for service systems, providers earn more by doing more. And, in our current physician reimbursement structure, procedural interventions are valued much more highly than are interventions that take time, thought and dialog with patients. Hospitals earn more by keeping their beds filled and device manufacturers/pharmaceutical makers’ profits are all dependent on increased sales whether the care is medically needed or not. How far we are from the concept of compensation based on how effective those providing health care services and supplies are at improving outcomes for patients!

Until we change the fundamental incentives in the system, we will never change the picture of health care spending in this country. Indeed, that’s what the parts of health care reform that deal with ACOs, PCMH, value based purchasing and the like are all about.

What is most concerning about this particular case is that – though Dr Midei was certainly extreme – the unnecessary provision of procedures for profit is more common in health care than most patients know. Let’s hope that the lawsuits are instructive to all practitioners who are tempted by the money in the system: over treatment/inappropriate treatment should not pay.

Many analyses of the impact of health reform focus on the large increase in expected Medicaid enrollment.  Indeed, our own analysis of potential Medicaid enrollment in Michigan showed as many as 452,000 people could be enrolled come 2014 (link to Cover Michigan) who are not enrolled today. Kaiser’s numbers were slightly higher, at 590,000 potentially new Medicaid enrollees, and more recent Census data suggest the numbers could be even higher. Whatever the actual number, all analysts expect a significant increase in Medicaid enrollment in Michigan over the 1.9 million enrolled in 2010.  Providers, states, businesses and community groups are all planning based on these expected increases in Medicaid enrollment.

But are these numbers real? And, does it truly make sense to plan on this basis? The November 24 New England Journal of Medicine had an important article on this topic.  Their analysis highlights how important it is to understand what’s behind the numbers as we think about what must happen in 2014 for these projections to become a reality – actual people enrolled in Medicaid.

A significant percentage of individuals identified in our study and counted as part of the expected increase in Medicaid enrollment in 2014 are not actually those who will be newly eligible for Medicaid in 2014.  Rather, they are eligible for Medicaid today and not enrolled. In our report, of the 452,000 who are not now but could be enrolled in Medicaid come 2014, 165,000 are already eligible. That means that almost 16 percent of individuals who are uninsured today are already eligible for but not enrolled in Medicaid.

Why is that? It’s a combination of reasons.

In some cases, individuals don’t enroll in Medicaid because they don’t want the stigma of being in a public program.  In other cases, it has to do with the difficulty inherent in the enrollment process, especially in Michigan. Staff at the Department of Human Services are overwhelmed with applications and their numbers are too few to handle even current demand.  The Department recently migrated to a new information system that should be helpful in the future but is not right now. And, many fast track options adopted by other states have not been adopted here in Michigan. So, the enrollment process is unpleasant and difficult for many.

The question is: will these issues be fixed with health care reform? Is there any reason to believe that the Medicaid take-up rate will be higher post 2014 than it is today?  The answer is that it could be, but that depends on a number of factors.  These include both changes that are inherent in the health care law and those that relate to the way the state implements the Medicaid expansion.

There are many incentives in health care reform that are different from today’s incentives and could encourage more enrollment in Medicaid. The most significant is the mandate requiring individuals to purchase health insurance. This mandate (assuming it withstands court and political challenges) is a significant departure from the current health care environment.  While the mandate can significantly change the environment, enforcement will be an issue.  First, those who don’t have any reportable income are exempt from the mandate. And second, it isn’t clear there will be adequate funding to enforce it as intended, or that this low income population would be the focus of enforcement.  So, this component of health reform may have less impact than some think.

The state has choices in Medicaid enrollment today.  It could have adopted many of the fast track options that were implemented by Wisconsin and other states. So far, it has not adopted all that it could. Going forward, the state could simplify Medicaid enrollment and engage in aggressive outreach to those who are eligible but not enrolled.

But even with the much higher match for the newly eligible population, the state will still need to find matching funds for almost 300,000 of those newly eligible and a higher match rate for the 165,000 who are eligible for the existing program but not enrolled. Will the state be aggressive as it could be in its enrollment efforts given the state budget challenges? We hope that 2014 will be a better economic year for Michigan than 2010 has been, but Medicaid already represents 22 percent of the state budget and its costs will continue to go up between now and then.  Will the revenue picture be such that the state will want to try and get everyone eligible enrolled?

Predictions are hard to make and our choices about the future are important.  For those counting on another half million individuals moving out of the ranks of the uninsured and into Medicaid, the decisions we make as a state over the next several years will be vitally important.

The Patient Centered Medical Home Model (PCMH) generates much discussion in health care circles. PCMH demonstration projects are widespread, accreditation organizations are developing and implementing certification programs for PCMH-based practices, and payers – including the federal government – are exploring new reimbursement policies to support medical home-based care.

There is a sense of urgency about implementing medical home capabilities. Yet many people express the concern that all of this is happening in advance of having a clear definition of a medical home or what the PCMH model actually means. Others say, “I’ve been providing a medical home to my patients since I started my practice. There’s nothing new here. This is just creating extra work for no purpose.”

I’m a bit surprised when I hear these comments and concerns. While multiple organizations have articulated PCMH definitions, the essential elements are always the same. And the sources of the ideas, which are very firmly grounded in common sense, are also identical.

In the 1960s, the pediatric community began describing the need for a medical “home” to identify needs and coordinate care for children with complex, chronic illness. These concepts informed the thinking of people at the MacColl Institute who described the Chronic Care Model, broadening the reach of these ideas to encompass all patients with chronic illness.

The Advanced Medical Home model was described by the American College of Physicians (ACP), expanding the scope further by applying the same principles to all patients, including those at risk for future illness and for whom preventive clinical services are indicated. The PCMH model was a direct outgrowth of the Advanced Medical Home model, representing a more refined articulation of the concepts which undergird all of these models. A summary statement from the ACP describes the model as a:

“…team-based model of care led by a personal physician who provides continuous and coordinated care throughout a patient’s lifetime to maximize health outcomes. The PCMH practice is responsible for providing for all of a patient’s health care needs or appropriately arranging care with other qualified professionals. This includes the provision of preventive services, treatment of acute and chronic illness, and assistance with end-of-life issues. It is a model of practice in which a team of health professionals, coordinated by a personal physician, works collaboratively to provide high levels of care, access and communication, care coordination and integration, and care quality and safety.”

A foundational concept is that the care be relationship based, involving an active partnership between caregivers and patients. The patient takes an activated role, owning the responsibility to identify personal health goals, work with the care-giving team in developing treatment plans, and actively engage in health behaviors, self-care, and health care seeking behaviors that advance his or her goals. The medical home team is responsible for assuring that care is coordinated across settings of care (e.g., specialists, ED, hospital, other facility) and over time.

While this vision is consistent with what most health care providers hope they can offer their patients, the scope of responsibility, level of engagement with patients, and systems needed to fulfill the vision go well beyond “what we’ve always done for our patients.”

An extension of the responsibility to coordinate care focuses on both the care patients receive during health care visits and the follow up on decisions and plans made at those visits. It also includes proactively identifying the needs of a population of patients, including their preventive and curative needs, and reaching out to people between visits to catalyze action to meet those needs.

The challenge isn’t so much about defining or describing the vision, but rather implementing the information systems and care processes necessary to achieve it and expanding access to medical home-based care.

There are no ruby slippers. You can’t click your heels three times and have a medical home. Simply paying providers to offer medical home-based care, hoping they do so, and then examining whether such payments yield better outcomes is a strategy which isn’t grounded in reality.

It is yeoman’s work to transform clinic practices from their current, acute-care focused, fragmented state and incorporate new systems and processes designed to reliably achieve the goals that flow from the PCMH vision for an entire community of patients.

The required capabilities include, for example, comprehensive patient registries to identify and track the needs of individual patients, manage the needs of a population of patients, and support performance measurement used in the process of continual self-assessment and practice improvement.

They also include modern information systems and team-based care management processes designed to meet the needs of patients with chronic illness. Achieving integration of these clinical systems and processes across medical home-based practices, and between those practices and their facility and specialist partners, is an even greater challenge.

This becomes clear when talking to people who are considering transforming clinical systems and clinic processes in an effort to modernize their practices. A common refrain is “I don’t know how to do this. You can’t get there from here.”

The challenge is daunting. For this reason, physician organizations in Michigan, in partnership with Blue Cross Blue Shield of Michigan, have created regional learning collaboratives designed to train physician organization leaders and staff in the workings of the PCMH model and in change management facilitation techniques so they can incorporate sophisticated process re-engineering skills into their core business. These efforts have catapulted physicians’ practices over the usual barriers to change and helped them incorporate new information systems and care processes, achieving improved efficiencies while doing so.

As evidence of this impact, PMCH-based practices in Michigan have already demonstrated improvements in access to primary care and reductions in the use of emergency department and inpatient services for chronic conditions. This work is not for the faint of heart, but can be transformative when practice teams are empowered to take it on.

Payers and purchasers, and the community in general, will see a much better return on their investments in the long run if they devote attention and resources to catalyzing and supporting provider organizations in their efforts to transform their office practices and integrate them into a system shared by their community of caregivers guided by the PCMH model.

David Share serves as Executive Medical Director, Health Care Quality, at Blue Cross Blue Shield of Michigan. Dr. Share also is the Medical Director of The Corner Health Center in Ypsilanti, a community-based health center for teenagers and their children, serving in this role since 1981. Dr. Share serves on the board of directors of the Michigan State Medical Society (MSMS), where he chairs the Committee on Michigan’s Public Health and the MSMS Task Force on the Future of Medicine.

Dr. Share is a key advisor to CHRT on many of its research and demonstration projects. He will be speaking about Blue Cross Blue Shield of Michigan’s PCMH implementation at CHRT’s December 2, 2010 symposium, Patient Centered Medical Home: Obstacles and Opportunities.

In 2006, there were 4.3 million children born in the United States. Approximately 55,000 of those children were born prematurely. Premature births have been increasing consistently since 1990 (though there appears to have been a slight drop in the rate of prematurity in 2007). In 1990, 10.6 percent of children were born prematurely; in 2006, that percentage had increased to 12.8 (preliminary numbers show a 12.6 percent rate in 2007 – still considerably higher than the rate in 1990). Last week, our center released an issue brief on this topic because we think it is such an important issue.

Why are premature births important? First and foremost, children who are born prematurely are at much greater risk for health problems than are children born at full term. The impact on families and the children themselves is enormous. In 2006, prematurity/low birth weight was the single largest cause of infant mortality in Michigan. In addition to being at higher risk for infant mortality, children who are born prematurely are at greater risk of developmental and behavioral problems later in childhood – problems that have a significant impact not just on the children themselves but also on families, schools, and the broader community.

Second, preterm births are costly. In 2007, the average charge for a premature birth/low birth weight delivery was $102,000 in Michigan ($119,000 in the U.S.), approximately 14 times higher than the average charge for a normal delivery. And, the cost differential continues in the first year of life. Average first year costs for preterm children in 2008/9 for Blue Cross and Blue Shield of Michigan (BCBSM) were $41,700 compared to $4,300 for children born at full term. Children born preterm with BCBSM coverage represented 10.3 percent of total births but accounted for 52.6 percent of total spending for all children in the first year of life.

Preterm births are not evenly distributed across the population. Black infants are 70 percent more likely to be born preterm than are white infants. And, prematurity is significantly more deadly for black infants than it is for white infants. In 2006, 5.6 percent of white infants in the U.S. died, about one third of those related to prematurity. In that same time period, 13.4 percent of black infants died with almost half due to prematurity.

And the extra tragedy is: we really don’t know why. We know that certain prematurity related risk factors (smoking, teen mothers) are more likely to occur with black mothers than whites, but even adjusting for these differences does not explain the disparity. Other theories have been posed but none have fully explained this difference or provided good guideposts on how to change this picture. And, children will keep dying or living compromised lives until we understand what is going on here.

Prematurity is unquestionably an area where we need further research to understand the causes and to develop more effective interventions to make a difference. Good research here could help save lives; improve the quality of lives of our children; reduce the burdens on our schools and communities who must deal with the longer term effects of prematurity; and, save significant dollars in the health care system and elsewhere in society. This is truly what public health is all about. So, let’s hope that with all the innovations and research being funded through the Affordable Care Act, particularly with the significant funding provided in the Prevention and Public Health Fund, the issues surrounding prematurity become a priority. After all, we are talking about our children and our future. What could be more important?

In the midst of all the focus on election day in the U.S., there was a much overlooked article the same day on changes in the British health care system. The article is about what is called in Great Britain “NICE.” NICE is an acronym that stands for National Institute for Health and Clinical Excellence. NICE was established in 1999 with a mission to help make evidence based decisions on the use of resources for health care in Britain. It publishes guidelines in three areas:

• The use of health technologies within the British National Health Service, including new and existing medicines, treatments and procedures;
• Clinical practice (guidance on the appropriate treatment and care of people with specific diseases and conditions); and
• Guidance for public sector workers on health promotion and prevention.

Health care in Britain is largely provided through the National Health Service, which is funded through taxes. In many ways, this system makes it clearer that resources are limited and choices must be made as compared to the much more decentralized and fragmented American health care structure. NICE was intended to both help make choices as to what services and procedures (particularly drugs) to cover and to provide more equity in coverage across the country – so that citizens in one part of Britain didn’t have different services covered from those in other parts of the country.

In a 2008 interview with NPR, Michael Rawlins, the head of NICE since its inception said:

“Paying huge amounts of money for every new drug with the faintest hope of extending life by even a small amount would make it impossible for the NHS to provide universal care.

The United States will one day have to take cost effectiveness into account,” he says. “There is no doubt about it all. You cannot keep on increasing your health care costs at the rate you are for so poor return. You are 29th in the world in life expectancy. You pay twice as much for health care as anyone else on God’s Earth.”

Indeed, NICE has been credited by health policy leaders around the world with helping to keep British health costs in line. And, while there has been general support for NICE by the British people there has also been periodic controversy.

In America, the Affordable Care Act included an entity that, when it gets fully up and running, will have some similarities to NICE. The Patient Care Outcomes Research Institute (PCORI) is intended to fund comparative effectiveness research on a range of health services. In its current structure the work of NICE is more explicitly linked to payment and coverage decisions than PCORI. The Affordable Care Act states that, “nothing in the law shall be construed as superseding or modifying the coverage of items or services under [Medicare] that the Secretary determines are reasonable and necessary or as authorizing the Secretary to deny coverage of items or services under Medicare solely on the basis of comparative clinical effectiveness research. “ This provision was inserted to counter charges that health care reform was going to “ration” health care. But, there are still many opponents of the ACA who say that the PCORI is truly intended to ration health care.

So, is America heading down the path that Britain is on and moving towards explicit rationing of care (as opposed to the implicit rationing we do today)? Well, as reported by the Wall Street Journal among others, in fact, Britain’s NICE might be moving to look more like America’s PCORI rather than the other way around. Indeed, the new Conservative led government in Great Britain is planning to limit what NICE can do to be advisory only and allowing drugs to be covered but with varied pricing set through “value based pricing” (hmmm – seems that even that term might have roots in America). And, when will all these changes take place? You guessed it – 2014 – the new Y2K in the health care world in America.

It looks like the pond between America and Britain just got a little smaller –with both countries’ health care systems, which have long been separated philosophically and structurally, coming closer together. Only time will tell whether the confluence is a good or bad thing for either country.

During the campaign, there was a great deal of talk about “repeal and replace” the Affordable Care Act if the Republicans won in Congress. Well, the Republicans won the House and made significant gains in the Senate. So, what now? Is a repeal of health care reform a likely outcome in the near future?

There is very little that is certain about the course of health reform over the next several years. But one thing is: the law won’t be repealed or replaced in the next two years.

Why? Well, the most obvious answer is that even though their numbers are fewer, the Democrats still control the Senate and President Obama is still in the White House and neither has any incentive to revisit the entirety of health care reform. Rather, it is pretty clear that the primary message of this election and the focus of the Democrats over the immediate future will be on the economy and jobs not on taking up anything significant about health care.

And truly, the message from the public about health care is more nuanced than it might appear from the results of the election. Kaiser did an analysis of the polls that asked Americans about their desire to repeal the Affordable Care Act and found that in actuality a relatively small percentage of the population wants a full repeal of health reform. A bigger percentage (but, still not an overwhelming majority) seems to want repeal of certain elements of the law, specifically, the tax on “Cadillac health plans” and the mandate to purchase health insurance coverage. Other elements of the law are things people say they want to keep. The requirement that children up to 26 can be on their parents’ policies, the rebates to close the prescription drug donut hole, the high risk pools and the insurance exchanges all get high marks in polls. And, when the question is asked about whether people feel that the law should be given more time, most people say yes – they want to see what it will be and are willing to wait before advocating for an outright repeal.

And, of course, the longer the law stays in effect and the more provisions that go into effect, the harder it will be to undo it in its entirety.

So, if it is unlikely that the law will be repealed in the next two years (and probably, no matter what the rhetoric is now, not even after the next presidential election, regardless of who is elected), what is likely to happen instead? Certainly those who ran on platforms opposing the law need to make good on the promise to do something in opposition to the current health reform law. While some will introduce what will essentially be “symbolic” bills to repeal the law, many of those who oppose the law will want to do something concrete to change it and not settle for a symbolic protest against the law. In this regard and even assuming the law survives the current court challenges it faces, the course of implementation of health care reform is fraught with challenges.

The most worrisome strategy that could be taken was outlined by Henry Aaron in a recent commentary in the New England Journal of Medicine. In a possible scenario that Henry Aaron outlines, repeal can become de facto based on how the budget and implementation issues are handled by Congress. That is, Congress could make it virtually impossible to implement health reform by withholding funding or making it difficult to get regulations enforced. In effect, the implementation would be shut down, which would mean we would have the worst possible world: a complex and comprehensive law on the books that cannot be realistically put into effect. In this scenario, everyone is a loser: the opponents of the law would not get a clean repeal and supporters (or even those who are agnostic about the law) wouldn’t be able to see if it worked as intended.

Clearly, this is not what the voters were asking for in the November 2, 2010 election. Indeed, what they said in every poll done to date is that they actually want government to work – and work better than it does now. But whether the newly elected (or re-elected) politicians will hear that message or not when it comes to health care reform is something that only time will tell.

Let’s hope they do. To face the kind of stalemate on health care that could occur from a “starve the beast” strategy on the Affordable Care Act is simply too depressing an outcome to contemplate given all the challenges we face in health care in this country right now.

On October 29, CHRT sponsored a symposium to look at issues surrounding the safety net and the future of health care after the Affordable Care Act takes effect. While there are some who believe that getting to (or close to) universal coverage would mean the end of the safety net, our panelists came to the opposite conclusion. That is, we all believe that in the reform environment, the safety net will be at least as important as it is today – perhaps more so. But demands on safety net providers will change when health reform is fully implemented and the structure and organization of the safety net needs to be ready for those changes.

The existing network of safety net providers – that is, federally qualified health centers (FQHCs), free clinics, and individual practitioners serving a mix of insured and uninsured patients – are today challenged in their ability to care for all who need their services. As individuals in our state (and every state) have lost health coverage, more are turning to this network of providers for critical care, and providers are overwhelmed with the needs and demands of this ever growing patient base.

Though one often hears that there is not enough funding to support these programs, in fact, many of the challenges faced by these providers have nothing to do with financing. Peter Jacobson presented a compelling look at some of the infrastructure issues within these clinic programs: noting that many of them have grown up over the years as a response to a critical need but without the structures that would be in place for most small businesses (measurement, clear lines of leadership, adequate IT systems, and the like). Indeed, some safety net providers felt strongly that their work was mission based and that they should be working themselves out of existence to be replaced by a re-vamped health care system. As a result, some never developed the kinds of systems that one would expect from an entity that was planning to be a going concern.

On the other hand, we know from the experience of Massachusetts and Hawaii that with significant expansion of health care coverage, the demand for primary care services increases significantly and with it, the importance of the safety net. Indeed, Sara Rosenbaum contends that the Affordable Care Act anticipated that demand and expects safety net providers – in particular, the FQHCs, to play a key role in delivery of care in the reform environment. In that context, the best of the FQHCs today operate in a manner that parallels the Patient Centered Medical Home approach. Those approaches will clearly be more critical post reform when there is a significant influx of individuals with Medicaid coverage.

Brent Williams emphasized the importance of the Patient Centered Medical Home model as he shared his clinical experiences in working with the uninsured – especially the low income uninsured – who often enter care with long untreated issues and a complex set of social as well as medical needs. With insurance coverage in the future, there is an opportunity to provide these individuals with earlier care and a more comprehensive set of services. But it will take time for the impact of these services on health status to be seen. The system will be challenged to think about ways to change traditional care patterns that rely on emergency room services and better integrate mental health and other supportive services into the safety net system.

Finally, our reactor panel of those on the ground at the community level caring for patients – Vern Davis Anthony, Deborah Riddick, David Share and Kim Sibilsky – all emphasized both the opportunity and the challenges ahead for the safety net. All agreed that the importance of the safety net will continue in a reform environment and that the challenges to respond to the demands in the future will be no less than they are today – just different as providers try to respond to the influx of new patients.

2014 may sound like a long time from now but in many ways, it is just around the corner. If we want to be ready with an integrated delivery system that builds on the many strengths of our current safety net providers but also fills in some of the gaps noted in Peter Jacobson’s research, we need to be planning today. We hope our October 29 panel was a start to that more formal planning effort in our state so that Michigan is prepared to lead the way.