Reinventing American Health Care: How the Affordable Care Act will Improve our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System

The definitive story of American health care today—its causes, consequences, and confusions

In March 2010, the Affordable Care Act was signed into law. It was the most extensive reform of America’s health care system since at least the creation of Medicare in 1965, and maybe ever. The ACA was controversial and highly political, and the law faced legal challenges reaching all the way to the Supreme Court; it even precipitated a government shutdown. It was a signature piece of legislation for President Obama’s first term, and also a ball and chain for his second.

Ezekiel J. Emanuel, a professor of medical ethics and health policy at the University of Pennsylvania who also served as a special adviser to the White House on health care reform, has written a brilliant diagnostic explanation of why health care in America has become such a divisive social issue, how money and medicine have their own—quite distinct—American story, and why reform has bedeviled presidents of the left and right for more than one hundred years.
Emanuel also explains exactly how the ACA reforms are reshaping the health care system now. He forecasts the future, identifying six mega trends in health that will determine the market for health care to 2020 and beyond. His predictions are bold, provocative, and uniquely well-informed. Health care—one of America’s largest employment sectors, with an economy the size of the GDP of France—has never had a more comprehensive or authoritative interpreter.

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1) Six Megatrends: Agree or disagree? - Ezekiel Emanuel just published an important book with a great title, "Reinventing American Health Care: How the Affordable Care Act Will Improve Our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System." In it, he describes the history of health care reform in the US, gives an overview of the Affordable Care Act (ACA), and speculates about future trends in American health care.

The concluding chapter of Emanuel's book is entitled, "Six Megatrends in Health Care: The Long-Term Impact of the ACA." I will devote this review to discussing his six "megatrends."

Megatrend 1) The End of Insurance Companies as We Know Them

Emanuel argues that health insurance companies will "shift their business to focus on offering services they have expertise in, particularly analytics, actuarial modeling, risk management, and other management services...." or "transform themselves into integrated delivery systems," or they will go out of business. This seems quite plausible. However, I think it will depend on how the ACA implementation goes over the next several years. If insurance companies raise their rates, there could be major political fallout.

Megatrend 2) VIP Care for the Chronically and Mentally Ill

Emanuel argues that "tertiary prevention" for chronically ill people with diabetes, heart disease, cancer, etc, and mental health care for people with depression/anxiety, will become an increasing focus of our health care system. I agree. I've taken care of many patients with chronic diseases and mental illness who cycle in and out of the hospital. The question is if our fragmented health system can provide coordinated, community-based care for these vulnerable people. Doctors and nurses must learn to use a biosocial approach when taking care of marginalized patients with chronic disease and mental illness.

Megatrend 3) The Emergence of Digital Medicine and the Closing of Hospitals

Emanuel writes: "Digital medicine will allow physicians to monitor patients remotely anywhere they are, get labs and many imaging tests done, and perform interventions once done exclusively in the hospital." I agree - sort of. We are rapidly headed into a digital era. More health care will be provided in the community, and digital devices will continue to proliferate. But will these digital devices provide value for money? Or will the hype outpace their effectiveness? Unfortunately, so far, the hype is winning.

Megatrend 4) The End of Employer-Sponsored Insurance

This controversial megatrend was analyzed in yesterday's front-page New York Times article. I think this megatrend is very difficult to predict. It depends on a number of political and economic factors. Will America's health insurance system remain constant, or will it move 1) towards a Republican system based on tax credits, or 2) towards a single payer system based on universal health coverage, or 3) a Kaiser-like group model? The latter is the most likely.

Megatrend 5) The End of Health Care Inflation

I'm definitely not an economist, but I'm not sure I agree with Emmanuel that the ACA will succeed at controlling the growth in health care costs. In his book, Emanuel admits that the ACA didn't go far enough on payment reform, and that there remains "a serious misalignment between what we want physicians and hospitals to do in terms of improving value, efficiency, and reducing unnecessary care and how insurance companies, Medicare, Medicaid, and others pay them." As long as our fee-for-service system is around, and Medicare payments and RVUs are biased towards specialists, the growth of health care costs won't be controlled.

Megatrend 6) The Transformation of Medical Schools

I agree with Emanuel. Medical schools must change, and become much more team-oriented, community health oriented, and digital medicine oriented. The problem is that medical school curricula are very difficult to change. Can they begin to change rapidly? I'm not sure. If they can, it will require a major awakening of medical students and faculty.
With the enormous amount of material for physicians to learn, does reducing the length of medical school from 4 years to 3 years really make sense? I don't think so. I think it would be preferable to keep medical school at 4 years and subsidize medical school tuition, or provide 100% debt forgiveness for medical students who enter primary care careers. The National Health Service Corps is a good program, but it doesn't go nearly far enough. If medical school is reduced to 3 years, will the training physicians receive really be sufficient?

By Philip Lederer on March 23, 2014

2) Excellent Overview of U.S. Health Care - American health care leads the world in costs - 18% of GDP (while excluding about 15% from insurance coverage), vs. 4% for Singapore (excluding no-one) at the low-end. It also infects 5% of hospitalized patients - of which nearly 100,000 die, and kills another estimated 44,000 - 98,000 from other hospital errors. Surely this complicated mess deserves rethinking. Unfortunately, getting from the mess we have now to something akin to the high-quality, much-lower cost care in Singapore, South Korea, Japan, and Taiwan has proven beyond the capability of America's legislative leaders. Decades of failed prior attempts, followed by compromise after compromise was required to even get the limited improvements afforded by the ACA when it was enacted in 2010.

Dr. Emanuel clearly likes the ACA - understandable given his role in its development. However, he minimizes trying to sell the ACA, doesn't mince words excoriating the initial ACA rollout efforts, and focuses on explaining our current complicated, dysfunctional system. I'm very hopeful that one of ACA's mandates (electronic medical records) will prove far more valuable than imagined, helping to identify important interactions, improve treatment protocols, and save lives. Improving access to care will also save lives. Similarly, encouraging the growth of accountable care organizations with bundled payments should also save lives and reduce costs by incentivizing quality improvement and removing incentives to over-treat. Finally, taxing 'Cadillac' plans will also hopefully make a dent in cost control.

An excellent and objective overview of complicated subjects.

By Loyd E. Eskildson HALL OF FAME on March 7, 2014

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