To Repeal and Replace Obama Care (ACA)? The initially proposed House of Representatives "repeal and replace Obama Care" legislation (The American Health Care Act of 2017 [H.R. 1628]) was estimated by the non-partisan Congressional Budget Office (CBO) to result in an additional 14 million individuals being uninsured, which would bring the number of uninsured Americans to 21 million in 2020 and 24 million in 2026. In 2026, an estimated 52 million people under age 65 would be uninsured, compared with 28 million who would lack insurance that year under current law (the Affordable Care Act). That effort lacked sufficient support and the highly anticipated vote was postponed on March 24, 2017. Subsequently, a revised bill passed the House on May 4, by a vote of 217 to 213 without any Democratic support. Interestingly, this was done prior to receiving an updated CBO impact statement.
The APA voiced its disappointment, resulting in APA President Tony Puente calling the legislation: "Significantly worse than the version considered last month. The bill now opens the door to health plans once again charging exorbitant premiums to the tens of millions of Americans with pre-existing conditions." The U.S. Senate is in the beginning stages of developing its recommendations – having to reconcile dramatically different, strongly held views among its members. For those concerned about mental/behavioral health and substance use services, the critical issue is whether the "essential services" provision of the current law are retained and to what extent the Congress might provide the various state Governors with sufficient flexibility to essentially eliminate the progress made over the past decades in enacting federal mental health parity legislation.
This ongoing national debate on health care reform is occurring within the context that the United States continues to spend more on health care than any other industrialized nation and without expected comparable health outcomes. Dean Art Kellermann of the USUHS School of Medicine reports that the National Academy of Medicine (formally, the IOM) estimates that we waste $750 billion per year on "unnecessary or inefficient services, excessive administrative costs, high prices, healthcare fraud and missed opportunities for prevention." Those primarily in private practice should appreciate that a significant number of health policy experts are increasingly coming to the conclusion that as a nation we are steadily approaching the enactment of a comprehensive "single payer" system under which government would play a major role in determining what is considered "quality health care" and what percentage of the economy will ultimately be allocated to these services. Since 1948, the World Health Organization (WHO) has taken the proactive policy position: "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." Without question, health care is a highly complex and evolving endeavor – with behavioral health often underappreciated.
State-Based Insurance Exchanges: The decision to establish state-based insurance exchanges, as envisioned by the ACA, was a major policy and operational commitment by 16 states and the District of Columbia. Last year the Milbank Memorial Fund sponsored a gathering of many of the original leaders of these exchanges to reflect upon the "lessons learned" and implications for future health system reform efforts by state policymakers. What should be the role of state government in assuring that their health system delivers on the goals of improved population health, efficient care, and a better patient experience of care? How to develop and maintain the capacities to implement agreed upon policy decisions?
The ACA provided three options for a state-based exchange's legal structure: public agency, quasi-governmental agency, or nonprofit organization, with each model being represented. Upon reflection, the directors expressed an overwhelming feeling of privilege and gratitude on being chosen to lead their state's historic efforts at building a state-based exchange. At the same time, many reported being challenged by the level of scrutiny, media attention, and political divisiveness that accompanied their every move. They emphasized the importance of having national and state political backing, both to support the launch of the new exchange and to build the broad public support needed to enroll those eligible for coverage. Retired US Navy nurse Coral Andrews, who was our Hawaii director, was particularly touched that President Obama personally joined one of their conference calls, lending moral and political support.
While all involved were deeply grateful for the opportunity to serve as director, they acknowledged that this was a very intense, 24/7responsibility. That only a relatively small number of the original directors remain in the role today reflects the demands of the position and the changing political support for this reform. For future state-based major health system reform efforts it will be important to remember that those recruited for these positions will need strong support from their state's leaders. Regardless of the political context and the policy positions adopted, certain capacities are needed to develop and implement major health reforms: clearly defined leadership, governance, roles, and mechanisms; staff capacity; and federal resources and assistance from other sources. Leadership was especially challenging because of what was described as working in a fishbowl-type environment, where they often faced a contentious political environment. Their strategy for dealing with this was to strive for bipartisan support and actively engage stakeholders.
All agreed that it was absolutely necessary to have a great relationship with and support from the Governor's office. It was important to secure the Governor's leadership to "prioritize operational practically over political opportunity." Having a strong advisory process was also viewed as critical and all agreed that the exchange structure must have "clear accountability with a single point of authority." Similarly, a clear and effective partnership with the Medicaid program, without being swallowed or subsumed by it, was necessary. Developing sufficient data to demonstrate progress to legislators and other stakeholders was extremely helpful. Not surprisingly, recruiting qualified and committed staff was a major challenge for all of the directors. Both public-sector and private-sector expertise was critical. The biggest recruiting challenge all of the exchanges faced was finding skilled IT professionals. Relying on a public-private partnership model requires a clearly articulated and shared vision to enable its success. Partnership models must align accountability and responsibility to optimize success. For all of us, the challenges and opportunities ahead are unprecedented.
Integrated Interdisciplinary Care: One of former APA President Susan McDaniel's personal priorities was preparing psychology for the evolving challenges occurring within the nation's health care environment. Integrated and interdisciplinary team-based care is one of the foundations of the ACA. Earlier this year, APA announced the development of an exciting curriculum for an Interprofessional Seminar on Integrated Primary Care, co-chaired by Jeff Goodie and Ron Rozensky. Fundamental change can be unsettling for many; however, visionaries such as Susan are laying an impressive foundation for the next generation of colleagues across the nation. "Oh, play me some mountain music." Aloha,
Pat DeLeon, former APA President – Division 42 – May, 2017
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