Kent Bottles: New Ideas for Covering Health Care in 2013

Barbara Feder Ostrov asked me to write a blog post about health care story ideas that journalists and bloggers might want to explore now that President Obama has been reelected.

I am not a journalist, but I do keep track of health care trends in my work teaching health policy at The Thomas Jefferson University School of Population Health and giving keynotes to health care and medical groups all over the country.

THE ACA IS THE LAW OF THE LAND

An obvious result of the election is that the ACA will not be repealed. Health industry players now know with certainty that the law that President Obama signed into law on March 10, 2010 will be the permanent statutory legislation that sets the ground rules and overall direction of health care delivery in the United States.

It is important for reporters to recognize that there have been three distinct phases of the ACA.

The first phase was the crafting of the law that resulted in bruised feelings on the left (no public option) and anger on the right (individual mandate).

The second phase was the attack on the individual mandate in the federal courts, which culminated in the Supreme Court of the United States ruling the individual mandate constitutional on taxing authority grounds and the reelection of President Barack Obama. 

The third implementation phase started on November 7, 2012 and will be complicated, tedious, and fraught with confusion for all involved.  One essential way to understand the ongoing implementation phase is to keep track of the timeline for ACA provisions through 2018.

The above description of the three phases of the ACA is oversimplified because some parts of the law are already in effect. While it is true that key provisions do not affect citizens until 2014, the following are already in effect:

* free preventive services,

* rescission where health plans can cancel coverage once you get sick is outlawed

* denial of coverage for children with pre-existing conditions is outlawed, and

* children can stay on their parents’ insurance plans until age 26.

THE STATES TAKE CENTER STAGE

Much of the most important action in the transformation of the American health care delivery system will shift from Washington, DC to the states.

Obviously, the U.S. Department of Health and Human Services (HHS) still will be a player as it issues regulations to guide the implementation process. Within one week of the election, HHS released regulations on essential health benefits, insurance rules, wellness programs, and quality metrics to the Office of Management and Budget.

But the real story of whether the implementation of the ACA will be successful depends on how states respond to their enormous role. 

A key provision of the law is the creation of insurance exchanges by January 1, 2014 in each state to facilitate the purchasing of insurance plans by individuals. As of November 2012, only 14 states and the District of Columbia had taken the necessary steps to establish an insurance exchange either by legislation or executive order, and insurance exchange legislation had failed to pass in 25 states. (See Barbara Feder Ostrov's post on covering health insurance exchanges in your state.)

The federal government will, by law, set up exchanges in those states that fail to do so, but some commentators worry about the bandwidth of HHS to accomplish such a large task. 

Others wonder how the states can make an informed decision without more detail about how the federally run exchanges would operate. NPR offers a useful overview of the insurance exchanges.

MEDICAID EXPANSIONS REMAIN UNCERTAIN

State governors also have to decide if they will participate in the Medicaid expansion that in the original ACA legislation was expected to cover 17 million Americans. The Supreme Court complicated this matter by ruling that the expansion was constitutional as long as states would not lose all their existing federal Medicaid funding if they decided to not participate in the Medicaid expansion.

Citing ideological principles, several Republican governors immediately proclaimed they would refuse to have their state be involved in the ACA Medicaid expansion. Such a decision would leave some citizens with no apparent way to obtain health care insurance that is required by the individual mandate.

Some analysts question the wisdom of such a decision by governors because hospitals and doctors would lose money, citizens of states that reject the expansion would be subsidizing health care in other states with their tax dollars, and the nine-to-one federal-to-state Medicaid funding match provided by the ACA would be hard to turn down in a time of strained state budgets. A detailed blog post written right after the Supreme Court ruling on this subject can be found here. 

INNOVATIVE STATE EXPERIMENTS

Many of the most interesting state initiatives in health care reform are occurring alongside Affordable Care Act implementation. Three states have shown considerable ingenuity:  Vermont, Oregon, and South Carolina.

On May 26, 2011, Peter Shumlin, the Governor of Vermont, signed into law plans to create Green Mountain Care, a single payer health care system that would comply with and build on the ACA. Vermont consulted with Harvard economist William Hsiao, who predicted that a single payer system would cut health care costs by 25% and save the state $500 million in the first year.

Shumlin has led Vermont to design the ACA health insurance exchange in such a way that it could be a platform for a single payer system in 2017 when the federal law provides more flexibility to states. In order to achieve his single payer vision, Shumlin will have to obtain waivers from Medicare, Medicaid, the ACA, and ERISA. He also will have to fend off criticism from the Republican minority in the state legislature, as the Boston Globe reports.

(Republican legislator) Burditt quoted V.I. Lenin, leader of the Russian Revolution and founder of the Soviet Communist Party, as saying "medicine is the keystone in the arch of socialism," adding, "I believe those who are promoting 'universal coverage' via government-run and government-controlled medicine know this. What they hope is that the public won't find out the truth. There is nothing compassionate about socialism."

Physician John Kitzhaber, Democratic governor of Oregon, obtained HHS approval to implement a $1.9 billion Medicaid program with Coordinated Care Organizations to decrease health care costs and improve the quality of care. The Oregon governor wants to slow Medicaid growth to a rate similar to the American economy. If the savings are not achieved, Kitzhaber will forfeit the $1.9 billion federal investment.

A Republican health care reform experiment that does not include participating in the ACA Medicaid expansion is occurring in South Carolina. Governor Nikki Haley is implementing Catalyst for Payment Reform, which features collaboration with private companies including GE, Boeing, and Wal-Mart.

There are many other local experiments that may lead to insights and solutions for decreasing per-capita cost and increasing quality. A valuable resource for learning more about local initiatives can be found at the Network for Regional Healthcare Improvement.

TINY DATA VS. BIG DATA

The reelection of President Barack Obama was due in large part to the Democrat’s skillful use of data and social networks to support a superior ground game to get out the vote. Republican and Democratic strategists both agreed after the election that the Obama campaign’s use of sophisticated microtargeting techniques was a key factor in the reelection of the President.

Experts and consultants believe that data and social networks are also a key to the transformation of the American health care delivery system. An important story that has not been adequately covered is the tension between those who advocate a “big data” approach and those who say “tiny data” is sufficient. The “big data” experts have the early mover advantage in this debate; one cannot attend a health care conference without being subjected to an expert explanation of how “big data” must be exploited and the speaker’s consulting services are critical to your Accountable Care Organization’s success.  

Steve Lohr provides the best short definition of big data that I have read:

Big Data is a shorthand label that typically means applying the tools of artificial intelligence, like machine learning, to vast new troves of data beyond that captured in standard databases. The new data sources include Web-browsing data trails, social network communications, sensor data and surveillance data.

Recently, some have pushed back against the “big data” approach.

Dr. David Kibbe and Vince Kuraitis have called on physicians to make better use of the limited data sets they already have available to decrease per-capita cost and increase the quality of the care they deliver. In their view, focusing on high risk patients, establishing registries for common chronic diseases, and partnering with payers for data and analytics makes a lot more sense than investing in an IBM Watson with a “large clinical data repository containing virtually every known fact about all of the patients seen by the medical group.”

Joshua Rosenthal, PhD offers a similar analysis and recommends health care organizations concentrate on “tiny data” to develop new business models that will be successful in this new era of providers competing on metrics being generated by Medicare and private insurers.

The AHRQ recent summary of data requirements needed for health care transformation is a good place to start an investigation into these important data issues.

BEHAVIORAL ECONOMICS TO ENGAGE PATIENTS AND DOCTORS

The successful reelection campaign of President Obama used behavioral economics techniques that could be emulated by the health care industry to nudge patients and physicians to adopt behaviors consistent with the ACA approach to health care delivery system transformation.

The campaign used insights from their consortium of behavioral scientists (COBS) to tailor their messages to voters. The experts advised that the best strategy to counter a rumor was not to deny the charge but to affirm a competing notion. Campaign volunteers used scripts that included scientifically proven ways to influence voters:  asking voters to sign an informal commitment card and to describe their plan on when and how they planned to cast their ballot. (http://www.nytimes.com/2012/11/13/health/dream-team-of-behavioral-scientists-advised-obama-campaign.html?pagewanted=all)

The lessons of behavioral economics are beginning to be applied to health and wellness goals. Companies such as Stickk, Aherk!, and Meta Real’s Virtual Fridge Lock are encouraging people to stick to their wellness goals by automatically donating to a disliked charity when one fails, posting an embarrassing photograph to your Facebook page when you fail, and alerting your social network when you raid the refrigerator. (/)

Two good places to get an overview of behavioral economics are Nobel Prize-winning economist Daniel Kahnemann’s book "Thinking, Fast and Slow" and Richard Thaler’s and Cass Sunstein’s book "Nudge."

Photo by Urban Bohemian via Flickr.

Related Posts:

After the Election, Some Fresh Ideas for Reporting on Health Reform

Covering Medicare before the election and beyond

Decision Time: States Weigh Their Options for Health Insurance Exchanges under Health Reform