The ACA: Far More than a Website

As we enter the depths of the holiday season, the narrative over the Affordable Care Act continues to cycle around the story-of-the-day.  On good days, these become real conversations about the challenges, both short-term and far, to improving upon an industry that straddles the public and private sectors and encompasses 18% of our GDP.  The ACA has laid the groundwork for a great number of shifts in how we look at both our health and the care we receive.  But there are always initiatives for improvement, tweaks to be made to help achieve its goals in a more timely and equitable fashion.  On the worse days, however- which lately seem to be out-shouting the good- critiques of the health care law and its implementation become the latest fodder for a media echo chamber where the competition is for the best chyron, the loudest host, the most shocking story.

Even more sober reporting now continues to focus almost exclusively on the faulty roll-out of the ACA website.  To be clear – most of the technical obstacles were foreseeable, and quite frankly unacceptable.  The memories of one or two college-level computer programming courses buried deep in the recesses of my brain have gotten far too much dusting off lately.  I am resentful that I can discuss the failures of waterfall approaches to IT development and the much more flexible and robust approach of agile development so fluently.  The fact that 834 forms are now in the public discourse – all of this has pulled us away from where we would thought the story would, and should be. But to focus on these as the crux of the story for health reform is sorely neglecting  everything else that the ACA represents and has already begun to achieve.

The first steps to revamp the website seem to be moving along, with a significant improvement cited by the administration by December first.  New oversight is in place, a new (and unfortunately late) emphasis on transparent collaboration between the administration, CMS, and private contractors building components of the websites seems to have taken hold.  More importantly, new efforts are being discussing to amend the way the federal government does  acquisition for IT projects.  The challenges faced by are not unique:  the VA struggles through its backlog to reconcile its systems with the armed forces, the armed forces struggle to integrate with each other, the intelligence community continues to struggle to across institutions.  All of these are symptoms of how large institutions with ingrained politics and interest groups are grasping for ways to enter the technological world many of us already live in.  But beyond the public sector, health care has long struggled with IT.  Electronic health records have proven a Sisyphean task to implement, across both public and private facilities.  Seeking to overhaul an industry upon whose successful functioning literal lives rely has been difficult long before the roll-out, and will continue to be so.  We would be far better off using the past few months as motivation to work for more extensive changes, both in the federal sector and without, to remedy the problems that have longed plagued these system- rather than boiling the conversation down to what this means for the 2016 elections.  3 years before said elections.  I know i personally can’t maintain my sanity with countdowns that would essentially be:  1000 days until the next thing that matters a lot!  365 until the next thing that matter a little!

So instead it is up to us to change the narrative, to help refocus the discussion on the real challenges, but also the real reforms that will play out over the next few years (and coming decades) to improve the state of our health, and in turn, our functioning as a happier, healthier society.  The administration recognizes this need: to encourage enrollment now that the first real deadline that matters is in sight.  And not for the media, but for real people:  December 23rd.  A premium paid on the new exchange by this day, and coverage begins January 1.  For many it will be the first day of a new experience with their health, one where they can be active participants rather than onlookers from the sidelines.  But in addition to this short-term priority- the administration, beginning today, will be rolling out a new campaign.  Each day- a different benefit will be highlighted, serving as a reminder to the public- and to us, in the medical community and media arena- why this was all so necessary in the first place.

This campaign coinciding with the holiday season works well to remind us of how much we have to be thankful for, despite the challenges which continue.  Just the issues highlighted in just the first week of the campaign are life changing for many of our fellow citizens who have gotten lost in the maze that healthcare has for so long been.

We will never go back to a pre existing condition making you uninsurable.  And with chronic illnesses on the rise, and the longest life expectancies seen in history- this is a trap that almost all of us would have eventually fallen into.  Never again.

Preventative services are now free.  No more foregoing screenings because of cost.  Now its up to those of us in the field to help ensure people follow through.  It’s easy for all of us to fall into the psychological disconnect between a small inconvenience now and a major risk in the future.  Even small costs have been should to discourage uptake of these services.  Now that barrier is gone.  The rest of it is up to us.

Insurers are now required to cover maternity care and cannot charge a higher premium simply for the outcome of the genetic lottery of being a woman.

Mental health parity is now a given, meaning insurers have to cover mental health just like every other medical diagnosis.  This will have far ranging effects, from helping people suffering from illness, to helping to end the stigma of seeking help for a malady every bit as real as one with physical signs, to helping afford new outreach programs which seem to get a brief spotlight every time a tragedy like a mass shooting event occurs.  These can’t fade into the background of “Wouldn’t it be nice if we could have done something” anymore.

Innovations in how we pay for care are just beginning to change how care is provided, how we incentivize good outcomes instead of just “more” outcomes.  Payments based on value of care, rather than quantity are rolling out.  Evidence of declines in avoidable outcomes like readmissions after discharge and hospital acquired infections are already showing great improvement, in only a few years.  Accountable care organizations creating multi-sector teams are working to treat the whole patient- as a person, rather than a set of kidneys, a heart, a blood pressure number.  And these are just in their infancy.

Changes in payment structures are also already playing a role in driving down the growth of health care costs to their lowest in decades.  For the past few years, annual rates of increase have fallen to 1.3%, more or less the rate of growth of GDP, an ambitious target long thought to be a reasonable level to seek.  A decade ago- growth was at 5%, and while some of this is attributable to the economic recession- it seems a good piece is left unaccounted for this way, meaning the changes being rolled out across the industry are likely creating institutional change which will have long-lasting effects.  Even the dialogue around how much we spend and how little we seem to get for it, has a real and measurable effect, meaning a different set of media narratives could have a real and lasting impact on health care, far beyond the page-clicks of the story-of-the-day.  And this impact is not limited to individuals- costs to Medicare, Medicaid, and other public programs will reap the benefits of these cost slow-downs, providing less expensive, verifiably better care to even more people.

Finally- we should be thankful that hundreds of thousands, if not more, fellow citizens are finally already able to receive coverage- through the health exchanges and states accepting Medicaid expansion.  At least 1.5 million people have enrolled in Medicaid or CHIP since October 1, and this with only about half the states taking up the Medicaid expansion to 133% of the federal poverty level.  The latest numbers floating around indicate a 4-fold increase in people signing up for private insurance on the federal exchange in November, up to 100,000 friends and family members across this country who now are guaranteed to same access to health care as the rest of us.  A record-setting December 1, early numbers indicate 18,000 people signed up for coverage, a daily record.  And yes, technical bugs still exist.  And yes, some individuals ran into problems.  But those individuals are fewer, and those times farther between.  And this number will continue to go down, and the number enrolled will continue to go up- and for this we should be most thankful.

The Affordable Care Act is far more than a website. Far more than just an individual market in upheaval.  As Deval Patrick summed it up, “It’s a value statement.”  And a statement we need to make sure is heard alongside the website problems, the policy changes, and anecdotes.  It is a statement of principles we stand firmly behind:  We all deserve a chance to live healthy, productive lives.  And the ACA is a strong beginning to that aspiration.

Affordable Care Act