The Obamacare Nobody Knows – Part 2

By David Adamson

Guarantee: If you click on a few of the links below, you’ll know more about Obamacare than 90 percent of Americans. If you read just one of the books at the end, you’ll know more than 99 percent, including most representatives in Congress.

When compared to Barack Obama, John Kennedy took the easy road when he chose to put a man on the moon as his legacy project. Reforming U.S. healthcare is infinitely more complicated.

David Adamson worked in high technology and health care. He’s the author of Walking the High Tech High Wire and The Wellness Club. He’s written hundreds of blogs on politics and fitness. Learn more about David…

Healthcare reform was a priority on Barack Obama’s agenda long before he was president. At the Democratic National Convention in 2004, he delivered an electrifying speech in which he first championed “the audacity of hope,” and warned against the false belief “the health care crisis will solve itself if we just ignore it.”

Arriving in the White House four years later, Obama had a responsibility to address soaring healthcare costs because the federal government’s share for Medicaid, Medicare, VA, and federal employee insurance accounts for more than 50 percent of total dollars paid to the system. Like we citizens, the federal government cannot afford it.

Because the federal government is the largest consumer of healthcare in the U.S., it has enormous negotiating clout. So, under the guidance of leading clinicians, insurance actuaries, healthcare policy wonks, hospital system CEOs, and other experts, Obama used his power to redirect the U.S. healthcare system.

What do you think? Take the short poll at the end of this blog.

As explained in Part I of this series, the Medicaid expansions and private insurance programs which opened healthcare access to over 20 million Americans is only part of the Affordable Care Act, which most Americans simply call Obamacare. In fact, the ACA includes 10 sections, and only two of the them pertain to expanded access. The other eight sections are designed to lower the cost by improving the quality of care for all Americans. No matter where or how you obtain healthcare in the U.S., it is now shaped by the ACA, and will be for a long time to come.

The ACA is structured to attain the Institute of Healthcare Improvement’s ambitious and worthy “Triple Aim”: 1) to improve the quality of care and patient satisfaction, 2) to improve the health of populations, and 3) to reduce the per capita cost of healthcare.

Here’s a glimpse into how Obama aligned U.S. healthcare with the Triple Aim in those eight hidden-in-plain-sight sections of the ACA. You might notice some of these when you visit your doctor:

Health Information Technology (HIT)

Nothing symbolizes the accountability expected with Obamacare more than the computer your provider has in the exam room with you (and may make you feel like your provider is paying more attention to it than you as s/he pecks away at the keys).

Dependent on information technology: The use of electronic health records adopted through Obamacare helps to speed up and increase accuracy of diagnosis and treatment.

President Obama signed the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009. It provided $19 billion in funds to providers serving Medicare or Medicaid patients, which is the vast majority of medical practices whether government funded or private, to adopt electronic health records. The technology push was made in anticipation of the ACA to enable the reporting of performance data that would be required from all providers and insurers.

In the exam room, EHRs help your provider do mundane tasks more quickly, like order labs, write online prescriptions to your pharmacy, or double-check if you are up-to-date on immunizations. Some EHRs even suggest a diagnosis for certain symptoms and recommend a treatment.

But another main function is to generate data to verify you are receiving high-quality care. This data shows up in various places such as the Healthcare Effectiveness and Data Information Set (HEDIS).

Prevention

Experts concur that the best way to reduce the cost of care is not to need it—by preventing a disease from developing in the first place, or intervening as early as possible when one develops.

Thus Obamacare requires insurers to provide preventive screening services, such as mammograms, colonoscopies, pap smears, and immunizations, for free or at low cost. These screenings are based on clinical evidence evaluated by the U.S. Preventative Services Task Force.

You might also get screened for depression and substance abuse because about one out of four visits to a primary care office have a mental health component. Obamacare recognizes mental health as a bona fide healthcare issue.

Prevention efforts extend to community health programs promoting smoking cessation, weight reduction, better eating, exercise, stress reduction, childhood immunizations, and fall prevention in the elderly. Obamacare also aims to improve what are known as the social determinants of health—non clinical factors that can make it impossible to live a healthy life.

Obamacare rewards your healthcare network for keeping you well, as opposed to just treating you when you’re sick. One way is through Pay for Performance (called P4P in healthcare circles). Another is through Accountable Care Organizations, a model to de-fragment care delivery through collaboration between primary care providers, specialists, and hospitals. (These integrated approaches did not originate with Obamacare, but have been tried and tested in health maintenance/managed care organizations since the 1970’s to the present. Think Kaiser Permanente.)

Quality of Care

Experts agree that high quality primary care reduces the need for costly emergency room visits and hospital admissions, therefore Obamacare includes financial incentives and punishments for quality of care.

Obamacare has been the subject of protests since it was proposed and then adopted in 2010. Protests, though, have been less vigorous than current ones against the various proposed versions of Trumpcare, which would result in increased premiums and millions of Americans without insurance.

Your provider’s organization might be a National Center for Quality Assurance (NCQA) Patient-Centered Medical Home , which has very stringent performance requirements, and uses a team approach to your primary care, as well as coordinates your care with specialists and hospitals.

If you have a chronic disease, your provider is following evidence-based clinical guidelines like these from the American Academy for Family Physicians. These guidelines are based on extensive research into what treatments have proven to be most effective. Adherence to clinical guidelines, documented in the EHR, gives you the best odds to get better or stabilize the disease.

You might be surveyed to obtain your feedback on your experience with your provider as patient satisfaction is factored into the final score your provider/plan receives, and the amount of their reimbursement.

Obamacare has already improved the health of millions of Americans and their communities, despite unrelenting efforts to sabotage it.

Obamacare has targeted preventative and quality of care.

Whatever happens to the ACA in today’s cynical, ignorant and corrupt political environment, Vice-President Biden spoke the truth when he whispered these words into Obama’s ear (and a live microphone) the day the ACA was signed into law: “This is a big fucking deal!”

It still is a big deal, a very big one. This is the last audacious hope we have to make the profit-driven U.S. healthcare system work for all of us.

P.S. If you want to delve deeper into healthcare, read these. All are written by medical doctors in accessible language. (If you have limited time or interest, get the first one.)

 

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The Obamacare Nobody Knows – Part 1

By David Adamson

(This is the first of a series.)

I was a foot soldier in the crusade to pass Obamacare.

David Adamson worked in high technology and health care. He’s the author of Walking the High Tech High Wire and The Wellness Club. He’s written hundreds of blogs on politics and fitness. Learn more about David…

Initially, it wasn’t by choice. I was the executive of a federally qualified community health center (FQHC) with outpatient clinics in rural mountain towns in Colorado. FQHCs, the linchpin of the national healthcare safety net, would play a frontline role in its implementation. Part of my job was to learn what was going to happen, when, and why.

I read books and articles, attended conferences and workshops, joined conference calls, and talked to high and low government officials. Most importantly, I read all 906 pages of House Resolution 3590, the Patient Protection and Affordable Care Act (ACA), which became known as Obamacare. Hidden within the legalese was the thinking of our best clinical and health economics and finance experts translated into policy.

Among the healthcare communities with whom I worked, word got out that I knew a little about the ACA, so I was invited to summarize it to county commissions, hospital boards, and public health departments who didn’t yet. I’d show graphs like this:

 

Then I would explain that our healthcare system had become a financial black hole, sucking in every free dollar, and closing in on 18% of GDP (it’s now 20%). Insurance premiums and deductibles were soaring out of control, as they had pre-Obamacare (and still are — in 2016 it was $25,826 for a family of four). They were squeezing out wage increases and other purchases, like vacations and college. Private sector American companies complained the cost of employee health insurance was making them uncompetitive in global markets. And uncompensated care delivered to the uninsured flooding emergency rooms was hurting hospitals. I’d finally present how the ACA would change this.

My time in the ACA crusade was an eye-opening adventure. Had I been more astute, I would have seen the anti-Obama, ultra-conservative onslaught coming that now plagues our body politic, starting with this troubling scene at a pro-Obamacare rally in Grand Junction, Colo., on Aug. 1, 2009.

Troubling scene: Protest at a pro-Obamacare rally in 2009 in Grand Junction, Colo. Photo by David Adamson.

Or two years later when I was requesting the support of a Republican county commissioner who dressed like a Wild Bill Hickok, right down to boots, duster, shoulder-length hair and handlebar mustache. We were planning a new clinic, to be partly supported by federal funds, in a town that was overrun by uninsured natural gas fracking workers with their attendant health problems, e.g., respiratory ailments, VD, alcoholism, and meth. He took me in his computer to show the National Debt Clock (it’s really cool), and, with sincerity, said that as a patriotic American concerned about our future, he would not support any project using federal funds because that would increase the debt. He added warmly that he supported what we were going to do (and did).

These days when Republicans threaten to repeal Obamacare, it’s obvious that they don’t know what Obamacare actually is. They didn’t when it was passed in 2010, and they don’t now.

Same protest at a pro-Obamacare rally in 2009 in Grand Junction, Colo. Photo by David Adamson.

President Obama could have enjoyed a long tenure in the White House without ever getting tangled with healthcare. As the hapless Republicans are about to discover, healthcare is dangerous for politicians. Corporate healthcare is not heavily populated with leaders whose values are inspired by Mother Teresa. If you threaten their profits, they will try to stop you. Obamacare has been profitable! (Remember insurers sponsored the ads that first branded Hillary Clinton as a cold-blooded, elitist bureaucrat when she tried to help Bill reform healthcare in the early 1990s, and the poisonous label stuck with her right up to her defeat in 2016.)

However, President Obama, a faithful Christian, believed that all people should have access to healthcare. Suffering, disability, and death may be part of the human condition, but access to modern medicine can often eliminate, reduce or postpone them. In his view, it was flat-out immoral that almost 50 million Americans were blocked from it. The Bible commands believers to heal the sick.

Also, one of the most visionary presidents ever, President Obama realized that the healthcare system itself poses a long-term threat to the US economy. He needed to act. It would be dicey; he would be like the kid in the boat with a hungry tiger in “The Life of Pi,” only he would have to finesse multiple tigers — insurance, pharmaceuticals, hospitals, nursing homes, provider associations, equipment suppliers, laboratories.

This already dangerous task was made worse by the ignorance, hostility, and, let’s be honest, racism of Republicans in Congress.

On Feb. 25, 2010, I stayed home from work with a wicked head cold and happened to flip on C-Span, which was live broadcasting the Health Care Summit, hosted by the President, for the leaders of both parties to exchange views about the bill.

Aware he was on national television, Eric Cantor, then Minority Whip, walked into the room with a hang-dog look on his face, carrying a foot-high stack of loose paper that he plopped down on a table with a dramatic sigh.

President Obama patiently watched this, then observed, “The truth of the matter is—is that health care’s very complicated. And we can try to pretend that it’s not, but it is.” At every opportunity, Republicans had been exaggerating the gross volume of the healthcare bill to frighten the public that it was packed with god-awful provisions such as death panels and socialized medicine. (Read the transcript here. President Obama knew his stuff.).

Senate Minority (now Majority) Leader Mitch McConnell, then and now the personification of active aggression towards President Obama, was in the room that day, sulking like always. But to his credit, he was listening because just last week, after releasing the Republican’s 147 page tax cut for the rich posing as a healthcare plan, he conceded that healthcare is “a big complicated subject.” Republicans have no plan of their own to improve healthcare.

Many of us, me included, would have preferred a single payer system like those in the rest of the industrialized world. However, President Obama was a pragmatist. He inherited an economy in the worst recession since the Great Depression. Support was shaky because of turncoat, deficit hawk Blue Dog Democrats. A single payer system was not a politically realistic option.

Facing reality, President Obama smartly neutralized the fears of the healthcare establishment, especially the insurance companies, by ensuring they would not lose money. He combined taxes on the rich, as well as several more obscure ones, and deficit spending to create access quickly. As a result, Obamacare has provided healthcare access to over 20 million Americans. That’s an amazing achievement.

Today no contorted Republican free market math can accomplish the same for less. Under any imaginable scenario, no matter how you fund access for the poor and people with pre-existing conditions, it will never be profitable and will have to be subsidized forever.

Obamacare was never just an insurance program. That’s why it was 906 pages long. It is the framework for a long-term transformation of our healthcare system to make it better and less costly.

It has already irreversibly changed the delivery of health care. You can see it when you go to your primary care doctor or into the hospital, if you know what to look for. In the long run, all of us, including Republicans, will be healthier because of it.