I once walked aimlessly for miles through fields full of land mines. Not on purpose, of course. It was in 2000 and I was vacationing in Mozambique while working as a Fulbright scholar in adjoining Zimbabwe. It wasn’t until 2007 that a survey conducted with 400,000 people in more than 6,000 communities showed that the Cahora Bassa area I was exploring had over 520 confirmed minefields.
Access to care does not necessarily produce good health, especially given current health disparities among different groups, says author Paul Terry.
The metaphor of “minefields” is often used to characterize the political polarity surrounding the Affordable Care Act (ACA). In Mozambique, even factions formerly bent on literally destroying each other are now working together to clear the land mines.
Yet as of this writing, Congress has voted on bills to repeal or alter the ACA 50 times. This is true even though no serious expert on either side of the ideological divide disputes that the American system remains the most costly sick-care setup in the world, one that delivers below-average population-level health improvement compared with the rest of the industrialized world.
Since the ACA was enacted in 2010, Americans have remained predictably divided on the law — even though a majority of us, according to a CBS News poll, want to leave the law as is (7%) or favor fixing it (48%). Indications are that as the disastrous rollout of the government health care Web site recedes in our rearview mirror, more Americans are accepting of the tenets of the law.
Still, as the November elections draw near, it seems clear that treading into health policy for incumbents and new entrants alike is like an invitation to Cahora Bassa. You simply don’t go there.
Where does that leave countless others of us who don’t identify, strictly speaking, with the politicians on either side of the ACA disputes? The explosive issues are too well known to venture aimlessly ahead, yet the need for continued reforms is too apparent to surrender the territory altogether.
“You need to find those reforms that both sides understand as positive,” says Dana Hughes, DrPH, professor of health policy in the Department of Family and Community Medicine and the Philip R. Lee Institute for Health Policy Studies at the University of California–San Francisco.
“People of all political leanings can relate to [ACA] features like coverage for young adults,” says Dana Hughes, DrPH, at UCSF.
“Policy change starts with stories about real people that we need to tell over and over again,” Hughes argues. “The ACA is not a perfect law, and it’s enormously complicated for the average person. But it does include some major technical fixes, such as subsidies for low-income families who do have insurance, that make a huge difference for families. And people of all political leanings can relate to features like coverage for young adults and for people with pre-existing conditions.”
With 30 years of experience in health policy, from working on the Hill to university-based policy research to teaching medical students about the policy process, Hughes often gets called on for her expertise in addressing the needs of underserved populations and the sickest among us.
“When there is controversy about a policy element like coverage for pre-existing conditions, responding begins with letting those who have benefited from policies tell their stories,” she says. “People need to hear what it’s like to have insurance and have access to care for the first time. Stories about what a difference coverage makes to the family budget, and how it alleviates the burden of cost worries and the emotional wear and tear on a family — those are the stories that inform the next agenda.”
While spreading the word about the newly insured is a vital preamble for “reform 2.0,” where should the conversation go from there? Some experts suggest that a clarion call needs to be sounded over and over. “Whether you support the ACA or not, we can’t only invest in our health care system,” says Tyler Norris, “We need to invest in what creates health in the first place.”
Norris, who is vice president for total health partnerships at Kaiser Permanente, also has an extraordinary professional portfolio of leading community health initiatives. “Given what we know about obesity and related chronic disease and the high costs our lifestyles are imposing, we need to create opportunities to invest in wellness,” says Norris. “We also need to address the barriers to people’s ability to access health-producing resources in the community, such as safe places to be physically active and affordable healthy foods.”
“Given what we know about obesity and related chronic diseases,” we need to invest more in wellness, says Tyler Norris of Kaiser Permanente.
Where “access for all” was the mantra for ACA supporters, could “health for all” be the code that cracks the policy impasse? Both Norris and Hughes name advancing health for and in communities as a policy priority, but they also worry about placing an inordinate burden on individuals with the fewest resources for making lifestyle changes. Accordingly, they pose wellness and equity as shared pathways.
“Taking an investment approach that focuses on a return measured by healthier people and places can help make care more affordable by lessening demand on the care delivery system overall,” says Norris. He suggests that “Getting to the actual determinants of health is one of the ways that we’re ultimately going to pull money out of the health care delivery system and make care more affordable.”
Though Hughes supports health for all in concept, she contends that “Wellness strategies are only part of the solution. We need to care about the structure of our health care system and how it’s financed, particularly for the poor, the elderly, and other vulnerable populations, because wellness strategies that produce benefits in the future can’t mitigate their need for quality health care today.”
Hughes doesn’t go so far as to suggest that the United States is ready to repudiate the market-driven health system, but she does foresee cost and quality problems continuing to fester under the ACA. For Hughes, the strategy for managing chronic health conditions starts at the roots of the problem, which are economic.
“The contribution of economics to our health crisis is twofold,” she argues. “In this country, health care, medical devices, drugs, and even research are commodities, rather than public goods, and we distribute them by market principles, not need.
“The other economic factor,” she continues, “relates to the disproportionate burden of disease among low income communities and communities of color. Health begins with equity. When we talk health policy, we must also talk about economic, social, and political equity.”
Where Hughes presents as a policy maven, Norris comes across as a “connector” à la Malcolm Gladwell when he discusses health policy. For him, health improvement starts with policies that marry economic interests with civic duties. Discuss health policy with Norris and you’ll find yourself on a public policy grand rounds that moves seamlessly from transportation and housing to urban gardens and pedestrian-oriented development.
Bring up cholesterol or obesity management and Norris will describe shortcomings of the farm bill. Ask about prediabetes and Norris will whack open a trail to transportation legislation.
“Kaiser’s grantmaking fosters convergence and partnering in communities,” he notes. “Chronic disease not only creates a lot of suffering — there is also a lot of cost. Together they make it our civic responsibility to act.” The connections among community partnerships, civic engagement, and health — on Norris’s policy playing field — spark a virtuous cycle.
To formulate health policies that foster shared responsibility for health, Norris thinks we need to stop blaming undisciplined or uninformed consumers of health and start speaking to people as members of the community.
“We all need to learn how to use the care delivery system well and get preventive care up front to help avoid longer-term expensive care,” he says, citing familiar themes. “But we are also now at a point where we need to engage with the delivery system and our communities and make investments that actually improve health overall” — early childhood education, return-to-work policies, chronic condition management services, and walking programs, for example.
“If we do these things well, we’ll have a healthier, more productive, lower-cost system creating less drag on the overall economy,” he says. “If we don’t act as a nation, we go broke.”
Affordable health, according to these policy experts, clearly doesn’t stop with affordable health care. Norris and Hughes begin with considering the determinants of health and the precursors to chronic health problems that in their view represent a threat to the entire economy. But swimming that far upstream, given how strong antireform currents are to begin with, requires both brilliance and bravado.
Few have more of those qualities than a physician who has practiced psychiatry in public hospitals for 30 years, has a master’s in public health, and has also run for Congress. (He was a candidate in a special 2009 election in the fifth Illinois district, including parts of Chicago and its near northern suburbs — Rahm Emanuel’s old district — but didn’t snag the Democratic nomination.) Running for the House of Representatives, says Carlos Monteagudo, started with “a kind of mad, just odd set of events, but I got a taste of politics and now I have the bug.”
I asked him how policy thinkers and political candidates can venture forth with new policy ideas when the ACA is such a minefield. “No matter what anyone says about the ACA, those interested in the next reforms need to be ready with a strong pivot,” he said. “It’s the law of the country, and it’s a good thing that we are now in an age where we’re going to cover everyone. The ACA has a lot of problems that we need to fix, but we don’t want to go back to the time when 40 million Americans were not covered, or when people used the emergency rooms for primary care, or when half of the insurance companies cherry-picked their patients, or when we got some of the worst care in the world at some of the highest prices. Considering the shortcomings of the ACA offers us the basic work plan for ACA 2.0.”
“The ACA has a lot of problems that need to be fixed,” says Carlos Monteagudo, MD. “But we don’t want to go back to the time when 40 million Americans were not covered.”
Given that Monteagudo was an attending psychiatrist at North Central Bronx Hospital, it should come as no surprise that he makes regular references to the crisis in primary care. In contrast to the brilliant documentary Escape Fire, in which a primary care physician quits because she has too little time to offer personalized care, Monteagudo is a highly trained specialist who spent far too much time providing primary care.
“I think the big question on everyone’s mind is whether or not the ACA is going to save money,” says Monteagudo. “The good news is that the insurance pool has expanded so that we have more healthy people paying into it. But from my experience as an EMS doctor, people come in all the time for care that is totally unreasonable to deal with in the emergency room or to handle situations that are way beyond the scope of our current medical system. I’m talking about homelessness, substance abuse, domestic violence, school bullying, and a host of other societal ills that find their way to the ER. I can only imagine 40 million more covered people coming to EMS to get the care that they should have gotten in their medical home or in some other more appropriate settings.”
Don Berwick, MD, the former administrator of the Center for Medicare & Medicaid Services who is now running for governor of Massachusetts, uses the Escape Fire metaphor to argue that fixing such obvious delivery system inefficiencies could allow us to rein in runaway costs. Yet, here again, health policy quickly intersects with other kinds of policy.
Groups not covered
“Right now, the largest uncovered group is folks that are undocumented: 12 million people who are showing up in emergency rooms and they’re not going to get coordinated care,” says Monteagudo. Like Hughes and Norris, Monteagudo thinks the solutions will as likely fall outside of traditional health system reform as they do within. And therein lies the possibility that debating the ACA, pro or con, is fighting the wrong fire.
“You need to start with the question of whether health care is affordable, not just to the individual but to the country,” he says. “Can we afford a system that uses an emergency room to treat social ills? We do need to minimize the abuses that happen in the system by both individuals and institutions.
“There is marginal quality when I see that 9 out of 10 people who come to the emergency room should not be there. It will take a cultural shift for people to stop using emergency services for self-limiting conditions or for basic primary care. It will take a cultural shift for institutions like schools, nursing homes, adult homes, programs for the disabled, and others to stop using emergency rooms to prevent lawsuits rather than provide care.
“We have to stop debating about whether we want to have the ACA or not. We have to start talking about these other issues instead.”
As for the ACA on the campaign trail this fall?
“There’s no avoiding it, so you might as well be proactive in a way that says, ‘I’m thoughtful about this. Here is how we create the cultural shift that has to occur. We’re going to be teaching about medical homes. We’re not going to be using emergency rooms any more for primary care or for lawsuit mitigation. We’re going to have to deal with homelessness and substance abuse and domestic and school violence and immigration reform and tort reform in better ways than we have thus far. We’re going to put as much focus on individual and community health and wellness as we have on making care accessible to all.’”
It wasn’t until I visited the larger towns in Mozambique that I began to notice the large numbers of locals living without arms or legs. That I returned from the Mozambique land-mine regions with all of my limbs was largely dumb luck, but also reflects my preference for hiking away from the well-traveled routes.
When you take the policy preferences of Hughes, Norris, and Monteagudo together, distinctive leanings away from the usual ACA debates emerge — not out of fear but because of their quest for a more interesting and edifying path.
They favor broadening the policy conversation to address health determinants that are not directly related to reforming the health care delivery system. When they think of ACA 2.0, the word “affordability” is attached to health, not care. And the way to affordability is through uncovering and better serving those living at the margins.
In the worksite wellness field, there is a growing trend toward undergirding individually oriented health management efforts with a focus on an organizational culture that truly supports and reinforces health.
This preference for smartly balancing individual responsibility with social responsibility for health comes through when Hughes speaks of market reforms, when Norris envisions “place making,” and when Monteagudo argues for creating culture shifts.
Policymakers and candidates dreading the ACA debates leading up to November will do well to consider how nimbly these experts navigate the land mines.
First, there is no avoiding the debate, so it’s best to be proactive and thoughtful about what’s next. Second, access to care doesn’t necessarily produce health, especially given current health disparities. And, most important, equitable access to health means traveling away from the current land mines anyway.
Taking a lead from these experts, it is time to stride unflinchingly ahead.