It’s been a year since the 2016 election, and perhaps no issue has been as defining – or divisive – as federal health care reform. Months of political tug-of-war over the Affordable Care Act has left lawmakers, hospitals, providers and patients with a bad case of whiplash – not to mention great uncertainty over the future of their healthcare.
The ACA was passed in 2010 with a long list of provisions, each carrying significant policy, financial and human implications. While all are worthy of a deep dive in policy analysis, the core of the ACA controversy has been its attempts to greatly expand the availability of affordable health coverage for Americans and radically reduce the number of uninsured. Specifically, its mandates requiring that individuals and business have coverage has caused much of the clamor surrounding the law. Programmatically, it provided the means to get coverage through an expansion of the federal Medicaid program and transforming the private insurance markets into marketplace exchanges, with means tested public subsidies.
Since Arizona expanded our Medicaid program, AHCCCS, in 2014, the uninsured rate across our state has plummeted – and an additional 400,000 of our friends and neighbors have access to affordable, vital healthcare coverage. Many, including me, hail this as a significant achievement, and worthy of maintenance and extension.
Now, the Arizona Supreme Court is considering a legal challenge to the very policy by which Medicaid was extended, with the potential to toss hundreds of thousands of Arizonans off the rolls. Meanwhile, on a federal level, it seems unlikely that we have seen the last of attempts in Congress to repeal and replace the ACA – efforts groups like mine have publically opposed because of their disastrous ramifications for patient care. Given the uncertainty that persists, is worth stepping back and asking why this fight matters.
Why does health coverage matter to so many? It is a question worthy of exploration and a reminder that it hasn’t always been so, nor does it have to be. There was a time when our health care system was more oriented to providing and supporting the supply of facilities and practitioners to deliver care, and helping to make it available once one got sick.
This coincided with the marvelous discoveries of the last century that have allowed us to care and cure. What were once death sentences are now the subject of routine miracles, and our early approach was to grow the capacity to do these things and make them more generally available. To the extent we tried to deal with the growing cost of doing so, this was done not so much through health coverage or insurance as much as “prepayment” mechanisms that tried to pool the cost of treatments for those that needed it.
Over time, this morphed into more of a health coverage and insurance approach, in part because of the growth of an insurance industry to provide this as a tool to manage our health care. Major growth in the role of government in health care financing spurred this market, and over time, groups of people deemed to be worthy of coverage grew, as did “health insurance” as the vehicle.
Research began to assess the value of health coverage, and today, a litany of studies confirms what those of us on the front lines of health care know to be true: health coverage leads to better outcomes for people, patients and communities.
Certainly one can also infer the financial benefits to those that are stricken with unexpected and costly need for medical interventions, and the sharp rise in the number of personal bankruptcies related to health care costs during the Great Recession provided a metric to support this.
Simply put, health care coverage is a good thing – and there is a basis for seeking to promote it as a public good with collective commitments. Even more, it is hard not to be touched by the personal stories of people who face health problems accentuated by not having health coverage to support their journey.
As a longtime observer of American health care, I would assert another very practical reason to advance and now protect health coverage as a primary solution. It’s one that we uniquely know, as only one of the only industrialized nations that does not provide some form of universally available health coverage for citizens.
This has forced us, over many decades now, to spend an inordinate amount of time and resources trying to rig up social systems to deal with the havoc this has created. The list of policy endeavors alone is a long one – some advanced by “left-thinking,” e.g., asserting a role for government – and others by “right-thinking,” e.g., advancing reliance on markets and economies. Still others are innovations of private entities and not-for-profit organizations.
The list is a long and complicated one. Hospital uncompensated care, charity care policies and laws, emergency treatment obligations, high risk pools, free clinics… and so on.
These are not only imperfect mechanisms, they are complicated and compromised by other initiatives intended to help solve the very same problem. Much of why our health care system suffers from being a not so good “system” is, in fact, these adaptations to solving the problem of the uninsured and the inordinate attention we must apply to managing them.
Part of the practical theory of trying to eliminate or greatly reduce the uninsured through the ACA was that by bringing most Americans into some workable form of health care coverage, we would be able to begin to minimize these adaptive solutions, simplify our system, and start to use our time and resources to actually solve health problems and improve health.
I have seen this taking root in the wake of the ACA, despite its imperfections in creating more health coverage and a lower rate of uninsured. Arizona, for example, is seeking more comprehensive solutions to managing behavioral health problems – and taking a big lead in addressing and combating the alarming rate of opioid addiction. Currently, we’re upping our efforts to improve end-of-life care through Thoughtful Life Conversations, which will continue to be a high-priority issue for AzHHA going forward. An increased focus on prevention and health promotion, including ways to increase personal accountability for health, are also coming down the pipeline.
To be sure, this remains a slow journey toward the promise of greater health. But count me among those who believe that we must find our way through the imperfections of the ACA policy and the current political fight by not throwing out the baby with the bathwater. We must find a way to continue to provide meaningful health coverage to the vast majority of Americans and Arizonans. As always, the Arizona Hospital and Healthcare stands at the ready and will continue to do our part to make that happen.