What's the prognosis?
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Whether or not you support the 2010 passage of the Patient Protection and Affordable Care Act, a.k.a. Obamacare or ACA, most probably can agree that the federal statute is a comprehensive attempt at tackling some of the nation’s most pressing health care concerns.
The constitutionality of the mammoth bill, which includes a mandate that individuals purchase health insurance or pay a penalty, has been challenged, and its fate now lies in the hands of the U.S. Supreme Court. The justices heard oral arguments in March and are expected to issue a ruling in June.
During the lawmaking process, Keith Mueller, professor and head of health management and policy in the University of Iowa College of Public Health, participated in congressional staff briefings on health care reform. The Milwaukee native holds three degrees in political science but has dedicated his career to analyzing health policy. He directs the UI-based Center for Rural Health Policy Analysis, which is affiliated with the Rural Policy Research Institute.
Mueller didn’t watch the Supreme Court proceedings (though he admits he has the transcripts tucked away, should time allow), but he is as anxious as anyone to see what unfolds. The court’s decision, he says, will affect the direction of his work.
Your research focuses on rural health care. What are some of the most pressing issues in that realm?
Continuing challenges include how we attain and retain sufficient resources in rural places to meet people’s health needs—something that, with advances in technology, is likely to be very different a generation from now—and how we allocate those resources. Also, many small, rural places don’t generate sufficient patient revenue to cover all of the fixed costs, so how do we financially sustain services in those areas?
We also are looking into designing a system that integrates local services with those from places like UI Hospitals and Clinics. Historically, we’ve had separate systems—a local system and a regional one—but given where we’re headed in health care costs and trying to slow down the rate of increase in costs, that’s not sustainable.
How does the ACA address these concerns?
In several ways. The legislation created a couple of new grant-funded programs for training health care professionals and also provides some incentive structures to help convince new health care professionals to start their practices in underserved areas, which include inner cities as well as rural areas. And there is increased support for the National Health Service Corps, a federal program that financially supports health care professionals who practice in shortage areas.
Also in the legislation are new ideas on how to redesign the health care system, the most notable one right now being accountable care organizations, or ACOs. ACOs are groups of health care providers who band together to coordinate and deliver high-quality care to patients. The ACA establishes guidelines for creating ACOs through a new program called the Medicare Shared Savings Program. The idea is that if you redesign a delivery system to put more emphasis on providing services outside the expensive environment of a hospital, for example, over time that will end up costing less for Medicare than if the patients had to be hospitalized. If the ACO can prove that it is generating savings, Medicare has to share those savings within the ACO. I just read that UI Health Care is working with Mercy in Cedar Rapids to develop an ACO. (You can read about it here.)
Care to make any predictions about the Supreme Court’s decision?
I’d say it’s probably 50-50. I think a lot of people were trying to read too much into the public part, but there is so much more input for the justices to consider—the written briefs, for example, and the discussions they have with each other.
Could the court strike down parts of the legislation and keep others?
I would be very concerned about what would happen if they rule that the mandate is unconstitutional—striking just that one section of the statute and nothing else—because a lot of the pieces of the legislation start with the assumption of maximum enrollment into insurance plans. Absent that incentive to buy health insurance, it will be very difficult for an insurance company to figure out how to provide coverage to everyone who asks for it regardless of their health condition and with no lifetime limits.
Other parts of the legislation, however, are not connected to the insurance provisions of the law—the Medicare Shared Savings Program, for example—and I see no reason why those couldn’t go forward.
How will the ruling affect your work?
It will certainly shape our research. The center that I direct here is one of two or three in the country that has been tracking and analyzing the characteristics of the uninsured population in rural places, and we will continue to do that no matter what happens, because there will continue to be uninsured people. Depending on what the ruling is, we’ll be looking at the differential impact of that outcome on rural versus urban.
What are the biggest misconceptions about rural health care?
The one that bothers me the most is that somehow rural health care is second-rate care. Rural health care is different; it’s not second rate. You don't have the same large, tertiary centers like UI Hospitals and Clinics in rural areas, but you do have comparable quality for primary care, short-term hospitalization, and emergency care. And the myth cuts both ways. There are serious inadequacies in quality of care in both urban and rural areas and, therefore, room for improvement in quality in both places.
Do you feel optimistic about the direction we’re headed?
Yes, I do. I think there are major changes under way in how we organize and pay for health care that will continue no matter what the political environment is now or in four years. Those changes will result in a new way of doing things. But I am not a health care provider—I’m not going to feel the pain that they’re going to feel. If these changes really take hold, it’s going to be painful. Money will change hands. Revenue streams will flow differently, and that means people whose expectations are at one level are going to have to adjust to a different level. Those of us in public policy have to think about how we create the bridge from what we have now to what a new and better system would look like.
Anything else that strikes you about this national debate?
I’m both pleased and displeased with public discourse over the past two years—pleased that there is a lot more public discourse around public health issues, but displeased that a significant part of that discourse stops short of full understanding.
One example is the debate that surrounded end-of-life care. The idea that providing payment for the time my physician might spend talking with me about the rest of my life somehow means that I’m going to be counseled to allow myself to die, a la a “death squad,” was a misguided debate. It’s important to have a well-informed physician-patient discussion about treatment options and care environment. The intent wasn’t to ration care or create death squads.
Misinformation can be just as dangerous as no information. The sound bite element to politics has always been with us, but the spin is a more recent phenomenon. It doesn’t mean that someone who is opposed to the ACA because they see it as big government is wrong, but let’s have an intelligent debate about the role of government and not jump to an accusation that’s not well grounded.