Primary care physicians will need to become comprehensivists mainly because of:

Chapter 14

The Future of Health Services Delivery

Learning Objectives

• To identify the major forces of future change and how they will affect health care delivery

• To assess the future of the Affordable Care Act and health care reform in the United States

• To discuss the components necessary to build a delivery infrastructure for the future

• To understand the special skills needed by future nurses, physicians, and other health care workers

• To evaluate the future of long-term care

• To appreciate the role of international cooperation in dealing with global threats

• To obtain an overview of new frontiers in clinical technology

• To survey the future of evidence-based health care based on comparative effectiveness research and patient-oriented outcomes research

“Will the U.S. have a single-payer system?”

Introduction

The future outlook of health care delivery in the United States is predicated on major current developments and the course these developments might take in the foreseeable future. On the other hand, any attempts to project the future of health care provoke more questions than answers, and the future often turns out differently than people anticipate (Kenen 2011). Even though most of the provisions contained in the Affordable Care Act (ACA) went into effect in 2014, its consequences, both good and bad, will be experienced for years to come. The health care industry has so far reacted by consolidating and forming organizational alliances in which hospitals, physicians, and in many instances, managed care organizations have integrated as major partners (see Chapter 9). The insurance industry has been dropping many individual plans because they do not comply with the ACA’s mandate to include essential health benefits (see Chapter 6). Many employers are trying to cope by reducing worker hours, negotiating new health plans, or sending workers to the government exchanges. By and large, the American people have remained passive, adopting a “wait and see” attitude.

When we look at health care delivery as an institution in and of itself, several external factors can be identified that would exert powerful influences for this institution to change and conform. Certain forces, such as demographic trends, project a foreseeable course, based on which some predictions can be made. For other external factors, even short-term predictions are difficult. For instance, it is impossible to predict the future course of the US economy and family incomes, both of which will affect what individual Americans and the nation may or may not be able to afford.

Future change also relies on historical precedents. Certain fundamental features of US health care delivery, such as a largely private infrastructure and the society’s fundamental values, have, in the past, resisted any proposals for a sweeping transformation of health care. Yet, certain historical precedents have also been used as a springboard for current change (see Chapter 3), and they will no doubt influence future change as well.

This chapter puts the future of health care in the larger national and global context. It also assesses the likely future course of health care reform, clinical technology, and new models of delivering health care.

Forces of Future Change

The framework presented here includes 8 main forces that help us understand why certain changes have occurred in the past, and they can help inform the direction of change that might occur in the future. This framework can be used not only for viewing health care delivery and policy from a macro perspective, but it can also be used by health care executives to craft strategies for their organizations that are aligned with the changes occurring in the broader health care environment.

The 8 forces are (1) social and demographic, (2) political, (3) economic, (4) technological, (5) informational, (6) ecological, (7) global, and (8) anthro-cultural. These forces often interact in complex ways, and these interactions are generally difficult to interpret. Keen observation of these forces, however, can create opportunities for change. How those opportunities are either garnered or forgone determines the nature of change. With the passage of time, some forces become more dominant than others. The directions of change these forces may portend have implications for cost, and hence, affordability; access to services; and power balancing within the health care system (see Chapter 1). Hence, the US health care system will continue to evolve, but nobody knows its ultimate destiny.

Another important point to bear in mind is the fact that for several decades now, the US health care delivery system has not been driven by free-market forces (see Chapter 1). Over the years, the government has become a major player that has controlled a growing segment of health care financing (see Chapter 6), and has increasingly wielded control over the private sector through its legal and regulatory powers. Yet, the government needs the private health care sector to serve its millions of beneficiaries in various public health insurance programs. At least for the foreseeable future, tension and power balancing between the private and public sectors will continue, and for better or for worse, we will see ongoing changes in the way Americans receive health care.

Another important point to keep in mind is the fact that health care encompasses almost one-fifth of the nation’s economy. The ongoing ability to deliver health care is, therefore, closely tied to the nation’s economic health, regardless of whether health care is delivered through private or public insurance programs.

Social and Demographic Forces

Demographically, the United States is getting bigger, older, and more ethnically diverse. Shifts in the demographic composition of the population, cultural factors, and lifestyles affect not only the need for health care but also how those needs will be met. Demographic trends will also continue to affect a nation’s ability to afford health care services.

The elderly, vulnerable populations, and people with certain health conditions all present varied needs. These groups are also among the highest cost drivers. Trends pertaining to the growing elderly population are covered in Chapter 10; almost all receive health care through Medicare, and a small proportion from both Medicare and Medicaid. Among vulnerable populations, disabled Medicare beneficiaries under the age of 65 have also been on the rise, from 13.3% of all Medicare beneficiaries in 1999 to 16% in 2009 (DHHS 2003a, 2012). During this same time period, Medicaid recipients (another vulnerable population group) increased by 56% (DHHS 2012). These expanding government programs are on an unsustainable financial path. According to the 2013 Medicare Trustees Report, the Hospital Insurance (Part A) trust fund will be insolvent in 2026 (Davis 2013). Supplementary Medical Insurance (SMI) trust fund is not projected to become insolvent simply because the government is obligated to fund the deficits from general tax revenues. In other words, general taxes must be raised or spending must be cut in other areas to keep funding SMI, which mainly covers payments to physicians (Part B) and cost of prescription drugs (Part D). Both Medicare and Medicaid face future challenges that still remain unresolved. According to the 2013 report of the Board of Trustees of the Federal Old-Age and Survivors Insurance and Federal Disability Insurance Trust Funds, retirement of the baby-boom generation—which started in 2011—will increase the number of beneficiaries much faster than the increase in the numbers of workers who will pay taxes. Cost projections by the Congressional Budget Office (CBO) estimate that Medicare, Medicaid, and Social Security will account for more than 90% of the growth in mandatory federal spending1 between 2013 and 2022 (CBO 2012). Only after 2050 will the baby-boom generation be gradually replaced at retirement ages by historically low-birth-rate generations, causing the beneficiary-to-worker ratio to decline. Until 2050, the state of the nation’s economy will be one of the key factors that will determine the future of Medicare, Medicaid, and also Social Security, the nation’s retirement program funded through workers’ payroll taxes, similar to Medicare.

An equally challenging factor is how population shifts affect the composition of the health care workforce, because health care delivery is labor intensive. In a free society, people choose their professions and where they work. As pointed out in Chapter 4, social and demographic factors have played a significant role in determining the number of health care professionals and their geographic distribution. Future immigration will be one factor that will affect the supply of health care professionals.

The society’s cultural mix, also based on the rate and quality of immigration, will continue to slowly transform health care delivery. For example, language and other cultural barriers affect both the patient and caregiver. Language training and posting of signs in different languages are only one small piece of the more complex cultural puzzle. Social and cultural factors affect exposure and vulnerability to disease, risk-taking behaviors, health promotion and disease prevention, and health care–seeking behavior. For example, non-Hispanic whites are more likely to visit physicians’ clinics, whereas non-Hispanic blacks more frequently seek care in emergency rooms. The large number of illegal immigrants, estimated to be around 13 million (Shrestha and Heisler 2011) and not covered by any health insurance program, including the ACA, also tap into the nation’s health care resources. The United States has failed to craft and pursue a well thought-out immigration policy. Hence, the effects of immigration on the economy and on health care remain unclear. Social and cultural factors also play a role in shaping perceptions of and responses to health problems.

To a large extent, population growth and aging are noncontrollable factors. Even individual responsibility for one’s own health is largely beyond the control of employers and the government, except that incentives created for people to engage in healthy behaviors to prevent disease and disability can have some effect. Personal lifestyles significantly impact the future of wellness, prevention, health promotion, and the burden placed on financing and delivery of health care. Despite its heavy focus on prevention, it is not clear to what extent the ACA will successfully change individual behaviors to make any significant headway in reducing the burden of disease in society.

Economic Forces

The national debt, economic growth, and employment are major forces that will determine the availability of health care services, their cost, and affordability. Besides employment, household income is a fundamental determinant of affordability, and both employment and personal income depend on the nation’s economic health. Yet, as more and more people start depending on government handouts, it will not prove to be a recipe for economic growth, just the contrary.

On October 31, 2013 (this is just an arbitrary date), the national debt of the United States stood at $17,156,117,102,204.49—surpassing $17 trillion (Department of Treasury 2013a). This is over 100% of the nation’s gross domestic product (GDP), estimated to be $16.7 trillion in 2013. The debt is the cumulative result of spending more than the revenues generated mainly through taxation. The deficit spending amounted to $1,089 billion in 2012, compared to $455 billion in 2008 (Department of Treasury 2013b). Deficit spending has to be financed by borrowing money. Whether this much debt can reach a point of crisis is a matter of controversy, but common sense suggests that all debts have to be repaid, nor can there be a default on the outstanding debt without jeopardizing the nation’s economy. If the debt was not a matter of concern, the United States Treasury would need not bother publishing the extent of national indebtedness. There also would not be a need to waste public resources on publishing the trustee reports for Medicare and Social Security; in fact, there would not be a need to have trustees. So, there are obvious concerns that the public debt must be reduced. The obvious solutions are the reverse of what creates debt—a combination of spending cuts, tax increases, and economic growth. High rates of economic growth can lower the need for spending cuts and raising the tax rates.

The recession ended in June 2009, but the pace of economic recovery and employment has been slow. In 2012 alone, the before-tax median household income of Americans, adjusted for inflation, had fallen 8.3% from the prerecession level in 2007 (Center on Budget and Policy Priorities 2013). The CBO projected the economy’s output to remain below its potential until the first half of 2018. Beyond that date, it is almost impossible to predict the timing or magnitude of fluctuations in the economic cycle (CBO 2012). One silver lining on the horizon is that the growth in the gross domestic product (GDP) is expected to exceed the growth in federal expenditures between 2012 and 2018 (CBO 2012). These projections assume that provisions of the Budget Control Act of 2011, which established automatic enforcement procedures to restrain both mandatory and discretionary spending, remain unchanged. In making these projections, the CBO made three main cautionary assertions: (1) Spending per enrollee for Medicare and Medicaid has generally grown faster than the GDP; if per capita costs grew just one percentage point faster per year than what the CBO has projected, spending for Medicare and Medicaid would increase by approximately $800 billion over the following 10 years. (2) The potential budgetary consequences of the ACA were uncertain. (3) According to the Sustainable Growth Rate (SGR) formula, which is part of the resource-based relative value scale (RBRVS) payment system to reimburse physicians (discussed in Chapter 6), physicians’ fees were to be reduced by 27% in 2012. Each year since the SGR was made part of RBRVS reimbursement, Congress has overridden fee reductions for physicians. If physicians’ fees are allowed to stay at their 2012 levels (without the reduction called for by the SGR formula), spending would increase by $316 billion over the following 10 years. In short, a lot remains unknown about future health care spending. National health expenditures are projected to grow one percentage point above the rate of GDP growth from 2012 to 2022, reaching 19.9% of GDP by 2022, up from 17.9% in 2011 (CMS 2013).

A golden prospect that has been left out of the CBO projections, and something that even most Americans are unaware of, is the oil and gas renaissance in the United States. Thanks to new technology and private initiative, the United States has become the largest energy producer in the world. This statement may surprise some, but it is true. Declaring energy self-sufficiency at this point, however, would be like counting chickens before they hatch. Yet, to the dismay of many in the business world, the trustee of the precious energy resources, the United States, does not have an energy policy for the future. Hence, much will depend on future energy policy which can either turn an abundant God-given resource into helping Americans financially or it can turn into a self-destructive weapon that “kills the goose that lays the golden eggs.” Judiciously harnessed, this one resource may well be the key to solving America’s looming economic crises.

At present, it is uncertain what effects the ACA would have on employment and household incomes. According to a CNNMoney poll of 14 economists conducted in September 2013, 9 indicated that businesses were putting off hiring in light of health care reform, even though the employer mandate had been pushed back until 2015 (Hargreaves 2013). Small businesses, for example, could cut hiring and reduce worker hours to keep their full-time equivalent to below 50 employees. Under the ACA, employers do not have to provide health insurance to workers who work less than 30 hours a week. The nonpartisan Employee Benefit Research Institute, however, has found that the trend toward more part-time workers—and less employment-based health insurance coverage—started in 2007, well before the passage of the ACA (Fronstin 2013). If this trend continues, the ACA could be a boon for part-time workers who can get government subsidies to buy coverage through the exchanges. However, the affordability of exchange-based health insurance remains unclear. In the long run, businesses make strategic decisions in the light of the various forces discussed in this section; hence, much remains unknown about future directions in employment and household incomes.

Political Forces

Chapter 13 discusses the role of politics and its influence on health policy. As should be apparent throughout this book, policy is closely intertwined with almost all aspects of health care delivery. Policies that affect education at home, as well as immigration policies, can determine not only the number but also the qualifications needed for the future health care workforce. The history of health care in the United States and in other countries is replete with examples of major changes brought about through political will. Politics serves a nation best when it is subservient to the people’s will. However, Americans remain divided on major policy issues, and health care is one such issue. It is anyone’s guess whether the ACA would have passed or failed had there been adequate transparency and public debate. The nation’s total economic spending and tax policies also lie in the hands of the politicians. Will they have the resolve, for example, to cut runaway government spending? Will they raise taxes to a point that severely stifles economic growth? These issues make national headlines during squabbles between the two political parties about raising the debt ceiling, meaning increasing the spending levels. Ironically, we do not hear about any collaborative efforts to reduce the debt ceiling.

Technological Forces

It is widely believed that technological innovation in medical sciences will continue to revolutionize health care. Americans strongly favor ongoing innovation, availability, and use of new technology. The high cost of research and development and subsequent costs of unrestrained use of technology, however, do raise questions about how long this can continue, given that the growth in health care spending will continue to surpass GDP growth. Yet, technologies that promote a greater degree of self-reliance and/or achieve cost efficiencies will receive much attention in the future. Nevertheless, the overall effect of technology is to increase costs unless it is accompanied by utilization control measures.

Informational Forces

Information technology (IT) has numerous applications in health care delivery, as Chapter 5 points out. IT has also become an indispensable tool for managing today’s health care organizations. Garnering IT’s full potential is still evolving and will continue well into the future.

Ecological Forces

New diseases, natural disasters, and bioterrorism have major implications for public health. These factors can even have global consequences. Diseases that are communicable—such as new strains of influenza—and those related to environmental agents—such as vector-borne diseases (for example, West Nile virus and chikungunya virus)—can bring about mass hysteria, particularly in large population centers, especially when the disease remains mysterious and treatments are not readily available. Zoonoses refer to any diseases or infections that are naturally transmittable from vertebrate animals to humans. Growth of populations around the globe will intensify the human–animal–ecosystems interface, raising the probability of engendering diseases that are yet unknown. When a significant number of people are affected or threatened by disease, research and technological innovation go into high gear. Technologies, such as remote sensing and geographic information systems (GIS), will find ongoing applications in public health and safety.

Natural disasters disrupt not only people’s daily lives, but also create conditions that pose serious health risks through contamination of food and water. Health problems and psychological distress often follow. Initiatives, such as biosurveillance and infrastructure upgrades, undertaken to cope with natural and man-made disasters are discussed in Chapter 2. The roles of the Centers for Disease Control and Prevention (CDC) and other partnering agencies will continue to evolve as new challenges emerge. On the down side, the growing need for combatting new ecological threats will divert resources from providing routine health care to patients.

Global Forces

The economies of the world are becoming progressively more interdependent. Globalization has become an extremely complex phenomenon, because the various forces discussed here interact as this phenomenon continues to evolve (Huynen et al. 2005). For example, Rennen and Martens (2003) define contemporary globalization in terms of an intensification of cross-national cultural, economic, political, social, and technological interactions. Hence, health and health care in various countries will continue to be affected in diverse ways through multiple pathways. To give a simple example, “brain drains” of physicians, therapists, and nurses from developing countries to relieve shortages in developed countries generally occur for personal economic reasons, but social, cultural, and technological factors may pose hindrances in the full utilization of their talents and learning. Economically backward countries have received “brain gains” as the number of health professionals from developed countries on medical missions to provide care in poorer countries has grown globally (Martiniuk et al. 2012). Medical missionaries do charity work out of a sense of deeply rooted personal ethics and compassion, but cross-cultural factors have at least some diluting effects on their optimum performance.

Other signs suggest that globalization in health care will intensify. Increasingly, generic drugs are being manufactured in Asian countries for export to Europe, Canada, and the United States. This trend has made drugs more affordable in the United States, but insuring safety and adequate supplies to meet demand on a consistent basis poses major challenges for the Food and Drug Administration (FDA). Medical tourism is likely to increase if high-deductible health plans (see Chapter 6), which give greater control to the consumer on how to spend their own savings on health care, continue to grow. Given the high cost of health care services in the United States and Europe, providers from other countries are providing or will soon be able to provide lower cost, but almost identically high-quality health services, and these services often come with greater amenities (Reeves 2011). Moreover, cross-border telemedicine used in conjunction with medical tourism is becoming a rapidly developing trend (George and Henthorne 2009). In the future, we may also see foreign hospitals and clinics providing services within the United States. Countries such as Japan, Norway, Australia, and India have asked for standardization of licensing and qualification requirements in the United States and/or to allow service providers licensed in one state to practice in all states (Arnold and Reeves 2006).

Anthro-Cultural Forces

Here, by anthro-cultural we mean a society’s beliefs, values, ethos, and traditions, which, in the health care context, are discussed in Chapter 2. It would also be helpful to review that the beliefs and values discussed in the previous chapters are espoused primarily by middle-class Americans. As pointed out in Chapter 3, American beliefs and values have historically acted as a strong deterrent against attempts to initiate radical changes in the financing and delivery of health care. Gallup poll results published in July 2013 showed that 52% of Americans disapproved the ACA, up from 45% in November 2012 (Gallup 2013a), as many more have learned about some of the details in this complex law. A survey in September 2013 conducted by the Pew Research Center (Pew) and USA Today also found that 53% of Americans disapproved of the ACA; 42% approved. Pew commented, “opinions are now as negative as they have been [at] any point since the bill’s passage” (Pew Research Center 2013). Looking ahead to the coming years, more Americans anticipate negative personal effects: 41% said the effect on themselves and their families would be negative; 25% said it would be positive, according to the Pew/USA Today poll. It is certainly not beyond the realm of possibility that the American public may end up deciding the final fate of the ACA.

The Future of Health Care Reform

Speculations abound that the ACA would eventually lead to a single-payer system , which is a national health care program in which the financing and insurance functions are taken over by the federal government. In fact, Senator Majority Leader, Harry Reid (D), one of the chief architects of the ACA, confessed in an interview that the United States needed to work its way past an insurance-based health care system and suggested that that would absolutely happen. He further stated, “Don’t think we didn’t have a tremendous number of people [Democrat lawmakers] who wanted a single-payer system” (McHugh 2013). So, will the United States have a single-payer system in the future? Perhaps, yes; perhaps, no. Much will depend on the ACA’s promises becoming reality, how it will affect the majority of middle-class Americans, and how the forces just discussed play out in the future. For example, if health insurance premium costs and out-of-pocket costs rise beyond what most people consider to be unaffordable, there could be a push for a single-payer system; however, it would require control of the presidency and the Congress to be in the hands of the Democratic Party, just as it was with the passage of the ACA. Conversely, mass dissatisfaction with the ACA would kill the prospects of a single-payer system regardless of who controls the White House and Congress.

Lessons From Massachusetts

Experience in Massachusetts may provide a window into the future of the ACA, because the basic features of the federal health care reform law were patterned after the Massachusetts health plan (see Chapter 3). Hence, with some caution, lessons can be drawn regarding the future of the ACA.

The Massachusetts plan has achieved some successes, but problems with costs remain the primary issue. As was expected, health insurance coverage increased markedly in Massachusetts between 2006 (before the plan was implemented) and 2010, including for those most in need of health care, such as individuals reporting poor physical or mental health (Dhingra et al. 2013). The proportion of uninsured fell to 12-year lows, from 11.5% in 1996 to 3.5% in 2008. The overall increase in premiums between 2009 and 2011 was 9.7%, far exceeding the rate of inflation. In 2012, 59% of the total enrollment was in HMO plans (Massachusetts Center for Health Information and Analysis 2013). For health insurance offered through the exchanges (called Health Connector in Massachusetts), the state set limits on the rise in premiums (Robillard 2010). It is possible that insurance companies were able to absorb the slack through the volume of newly insured customers and by shifting costs to employer-based plans. Among Massachusetts residents, 62% had employer-based coverage (Massachusetts Center for Health Information and Analysis 2013). Whether limits placed by the government on rises in premiums can continue in the future remains to be seen.

The overall prevalence of unmet needs because of inability to afford health care fell from 9.2% in 1996 to 7.2% in 2008. However, this was not the case for middle-income earners, Hispanics, Blacks, and those in fair to poor health (Clark et al. 2011). Although disparities may remain in some areas, for some surgical procedures racial disparities were actually reduced (Loehrer et al. 2013). The overall volume of emergency department utilization has continued to rise, with only a small decrease in the rate of low-severity visits (Smulowitz et al. 2011). The likely reason is a shortage of primary care physicians (PCPs), even though Massachusetts has a high number of PCPs and the state improved its primary care capacity by increasing the number of nurse practitioners and physician assistants. Conversely, hospitals experienced a significant decline in charity care and uncompensated care (Edwards 2010).

In the 2013 health care public opinion survey, the Massachusetts Medical Society reported 56% of those surveyed were satisfied with the health care they received. Two main concerns expressed were cost and waiting times to see a physician (Massachusetts Medical Society 2013).

The Massachusetts law focused on expanding coverage, leaving cost containment “for another day” (Mechanic et al. 2012). As time progressed, health care expenditures became the biggest challenge. After three rounds of reform legislation, a fourth round, called Chapter 224, appointed a health policy commission with a variety of regulatory powers that include limiting health care cost growth to mirror the state’s economic growth and reducing Medicaid payments to providers (Barr 2013). Governor Deval Patrick also proposed an income tax hike, in addition to higher taxes on gasoline and tobacco.

Likely Experiences Under the ACA

One main caution in translating everything from Massachusetts and applying it nationally is that one state does not represent the ethos of the entire country. As pointed out earlier, before the ACA was fully implemented a significant proportion of Americans were opposed to the law. In 2011, even though 96% of physicians were accepting new patients, 31% were unwilling to accept new Medicaid patients (Decker 2012). The main reason is low reimbursement and delays in receiving payment from Medicaid after services have been delivered. To assess physician perspectives about the ACA and the future of the medical profession, a 2013 survey of US physicians conducted by the Deloitte Center for Health Solutions (Keckley et al. 2013) pointed to a relatively high level of dissatisfaction, particularly among PCPs, among whom only 59% were satisfied with their profession. Six in 10 physicians indicated that many would retire earlier than planned based on how the future of medicine was changing. Six in 10 physicians also indicated that the practice of medicine was in jeopardy. In addition, physicians thought that their take-home pay was decreasing as a result of the ACA; inadequate reimbursement in the future was one of the main concerns expressed by 90% of physicians. To address the problems in the US health care system, 44% of the physicians thought that the ACA was a good start, while 38% believed that the ACA was a step in the wrong direction. These results contradict findings from Massachusetts where a large number of physicians (70%) supported health care reform (SteelFisher et al. 2009). Of course, it is possible that negative sentiments expressed by the American public and physicians could dissipate as time progresses. For example, it is possible that as time progresses, an increasing number of people would feel like winners under the ACA. Physicians who feel like quitting may find that they have no other choice but to carry on in their chosen profession. Conversely, it is also possible that the concerns expressed could pose serious challenges to the ACA in the future. The general public and the physicians may hold the key to the future of the ACA.

Based on the experiences in Massachusetts, the ACA will decrease the number of uninsured, particularly among vulnerable and low-income population groups. However, the law fails to achieve universal coverage, leaving 25 to 30 million uninsured, even though reductions in the number of uninsured would be quite significant. Of greater concern, however, is access to health care by the 25 million newly insured between 2014 and 2023, as estimated by the Congressional Budget Office (CBO 2013). The shortage of primary care physicians (PCPs) will be a major barrier to access. The access dilemma is compounded by the fact that states with the smallest number of PCPs per capita overall, generally in the South and Mountain West, will also see the largest percentage increases in Medicaid enrollment (Cunningham 2011). Mirroring the experience in Massachusetts, the ACA presages greater government control over health care through stifling regulations, lower reimbursement for providers, higher costs, and higher taxes.

Keeping cost escalations within reasonable limits will remain the major challenge. People will negatively react to any significant increases in their out-of-pocket costs. Physicians particularly will react to cuts in their personal earnings. The ACA’s effect on jobs and the economy is uncertain, although a number of employers have reduced worker hours to avoid offering health insurance. In a Gallup poll, 41% of the small business owners indicated that they had held off on hiring new employees, while others had reduced their number of employees or had reduced employee hours (Gallup, 2013b). In addition, 48% of small business owners indicated that the ACA would be bad for their business; only 9% thought that it would be good.

As stated previously, it is too early to draw definitive conclusions at this point. Yet, prevailing current negative sentiments may be difficult to overcome and may actually intensify if the promises of the ACA do not materialize. If negative sentiments intensify, the lawmakers will have no choice but to repeal the major provisions of the ACA. Can that happen? Absolutely, yes. There is precedent for it. The now-forgotten Medicare Catastrophic Coverage Act of 1988 was passed by a wide margin by both houses of Congress and was signed into law by President Reagan. In short, this law had proposed some reductions in out-of-pocket costs in both Part A and Part B, and had added prescription drug coverage beginning in January 1991. The expanded benefits would be paid for by an additional income tax to be paid by an estimated 40% of the elderly. This law became highly unpopular among the elderly, many of whom did not even understand it. Roughly 45% of the elderly had private health insurance, mainly through a previous employer, and they were satisfied with their coverage. A ground swell of negative public reaction forced Congress to repeal the legislation only 17 months after it had become law (Rice et al. 1990). Whether Republican or Democrat, politicians react to overwhelming concerns expressed by their constituents.

Finally, how much the ACA will end up costing is a major issue. Suspension of enrollment in the Pre-existing Condition Insurance Plan (PCIP–see Chapter 6) is perhaps an early warning sign of trouble ahead. On February 16, 2013, the federal government suspended acceptance of new enrollees in PCIP, even though it was a temporary measure until the mandate for insurance companies to cover all pre-existing conditions went into effect in January 2014. The explanation given by the government was that suspending further enrollment “will help ensure that funds are available through 2013 to continuously cover people currently enrolled in PCIP” (US Government 2013).

It would be fair to say that the ACA still faces headwinds, and its repeal is not completely out of the question. If a repeal should occur, however, that would not kill the prospects for future health care reform. Hence, the question, “What if?” is still a legitimate one as it could well pop up in the future.

What If?

What if the law gets repealed? Or significantly altered? Or funding to implement it gets slashed? Or it fails to deliver on its major promises (outlined in Chapter 13)? These are big questions that will be decided in the near future, most likely between 2014 and 2016. Regardless of what happens, the seeds for health care reform have already been sown, and it will no longer remain a dead issue. Any future reforms would build on rather than scrap completely some of the provisions in the ACA. For example, the exchanges established under the ACA would likely survive, as they have been proposed by Republicans in the past. Medicaid would likely be left up to each state to deal with, although it would be difficult to scale back in states that have expanded Medicaid under the ACA. Federal subsidies, in one form or another, to assist individuals to buy health insurance would likely be retained as the Republicans in the past have proposed tax credits and vouchers to purchase health insurance. In terms of coverage, requiring health plans to cover preventive services would be retained, but other ACA mandates would be relaxed. High-deductible health plans (see Chapter 6) could play a significant role in any future health care reform. Researchers Haviland and colleagues (2012) estimated that growth of these plans from the current level of 13% to 50% would reduce annual health care spending by about $57 billion.

To reduce health insurance premiums, coverage of pre-existing conditions would likely be returned to the states who would manage their own high-risk pools as before. High-risk pools were created by about 35 states to make health insurance available to people who otherwise would have been uninsurable because of pre-existing health conditions. What could be repealed are the most contentious requirements of the ACA, namely, the individual mandate, the employer mandate, and the mandated essential health benefits. Other changes could include tort reform to mitigate the effects of malpractice lawsuits against physicians. Overall cost control, however, will continue to be a nagging issue for which there are no easy solutions.

Universal Coverage and Access

There is no question that the United States needs some type of universal coverage, but the nation first needs to strengthen the health delivery infrastructure. Lamm and Blank (2005) cogently stated that universal coverage is feasible, but, to financially sustain such a system, Americans will have to “give up a cherished dream: the dream of total, universal care for any ailment freely available on demand.” Hence, a change in mindset will be necessary. As Paulus and colleagues (2008) have proposed, the underpinnings for a change in philosophy should be to seek value in health care. It necessitates asking the questions: What do we propose to get in return for what we pay? How much should we pay for what we should reasonably expect to get? The pillars of a value-driven system will be individual responsibility for one’s own health, self-management support, patient activation, preventive services coupled with health education, and an infrastructure based on primary care. A health care system built on these pillars has the potential to return the biggest dividends in improving health at a reasonable cost.

The main barriers for moving the US health care delivery system toward an ideal state, of course, pertain to the American mindset in terms of expectations and inadequacies in the existing infrastructure that fall far short of what is necessary. Government policy that works collaboratively with private payers and providers to create strong payment incentives will be needed to tip the scale toward primary care in which both physicians and nonphysician practitioners will play mutually supportive roles. Regrettably, crafters of the ACA did not seek this type of consensus; they merely believed that creating a law with stiff mandates would automatically achieve the results most Americans would desire.

The big unknown factor is whether US medical students would react to incentives and choose to enter primary care in sufficient numbers that tip the scale. It can perhaps be achieved over time by working collaboratively with the Council on Graduate Medical Education. Immigration reform could also entice sufficient numbers of physicians to practice in the United States. These efforts, however, would take several years to achieve their goal, and may also raise concerns about the quality of care.

To get some perspective on universal coverage in the United States, Hawaii and Oregon have the longest running programs that have attempted to eliminate the uninsured in these two states. In Oregon, despite the expansion of Medicaid and rationing of care, 15.6% of the state’s population was uninsured in 2006 (Office for Oregon Health Policy and Research 2007). In Hawaii, 8% of the total population was estimated to be uninsured in 2009, according to the Henry J. Kaiser Family Foundation (Kaiser 2014).

What the nation should try to achieve is a near-universal system that provides basic health care to at least 95% of the population. As described in Chapter 1, Singapore switched from a British-style governmentrun system to one in which the markets and people’s self-reliance play a greater role and the government is responsible for providing health care only to the most needy. In the United States, high-deductible health plans with savings options, regular health insurance, defined contributions by employers toward purchase of individually desired health plans, financial contribution toward health care by everyone (with only a few exceptions), reformed Medicaid and Medicare, and charity care can all play a role in bringing about near-universal coverage and access under the umbrella of a consensus-driven government policy.

Under such a system, delivery of health care to all citizens is not the primary function of government. Experts sometimes decry the administrative costs and inefficiencies in the US health care system, but they do not take into account the inefficiencies and loss of productivity attributable to ever-increasing government regulations.

Single-Payer System

Many developed nations have been able to achieve universal coverage through a single-payer system, and their citizens have been able to accept supply-side rationing for specialty care and higher taxes. Thanks to a strong primary care system, these countries are able to provide basic services to nearly all citizens. In the United States, if this possibility exists, it appears to be far in the future.

As discussed previously in this book, despite notions to the contrary, a government-run, single-payer system does not achieve universal access —the ability of every, or nearly all, citizens to obtain health care when needed. This is because rationing is easier to achieve in a system financed entirely by the government.

One major advantage of a single-payer system is that all Americans and lawful residents would be entitled to some benefits. Private insurance plans and government entitlement programs (that is, Medicaid, Medicare, TriCare, and the Federal Employee Health Benefits Program) would no longer be necessary, although the market for some private insurance will remain for those desiring coverage beyond what a basic government plan might offer. Given that the United States has largely a private infrastructure for health care delivery, an American single-payer system would resemble the system in Canada (see Chapter 1). Costs would be contained through supply-side rationing, and higher taxes would be necessary to sustain the system. However, both rationing and taxes are likely to be resisted by the American public and most physicians.

Delivery Infrastructure of the Future

The future health care delivery infrastructure will evolve by incorporating the models and concepts described in this section. Some of these models and concepts are referenced in the ACA, but with little concrete proposals. They have been used on a small scale, and their widespread adoption is a few years away. Yet, some organizations have implemented the ideas presented here and have achieved positive results.

The health care infrastructure will continue to evolve, driven by an overarching concept of high-value health care focused on lowering costs, improving quality, and engaging patients in health care decisions. Yet, one model will not suffice to meet a variety of needs. Hence, many of the current structures of health care delivery will remain.

Future payment methods will also incorporate at least a value component. The evolutionary changes will also transform some of the traditional processes of health care delivery by placing an increased emphasis on evidence-based care and processes that eliminate waste. For example, improved surgical scheduling practices can reduce delays and cancellations of elective surgeries (Cosgrove et al. 2012). Redesigned workflows can improve efficiency. Cost-saving technology will play an increasing role in reformed processes of care. Finally, new approaches will be used to target programs to the needs of patients in the community who present specific health risks.

Physicians and nurses will have to be trained to practice in a wellness-oriented model of care delivery. To some extent, the delivery system will evolve to replace periodic encounters between patients and providers with an ongoing relationship that includes remote monitoring of health status and virtual consultations (Adler et al. 2009).

Implementing the Medical Home Model

The main concepts behind the medical home model are discussed in Chapter 7. Four critical issues have been identified in the implementation of this model:

1. Qualifying a physician practice as a medical home: A valid tool should capture the capabilities a medical practice should have to qualify as a medical home. This can help medical practices focus on the most important activities that would improve care. Research shows that four key primary care elements—accessibility, continuity, coordination, and comprehensiveness—positively affect health outcomes, satisfaction, and costs. An ideal qualification tool would ensure that medical homes are built on a firm foundation of these four pillars (O’Malley et al. 2008).