The Continuing Evolution of Obamacare: "Skating to where the puck will be" 

We can never insure one hundred percent of the population against one hundred percent of the hazards and vicissitudes of life, but we have tried to frame a law which will give some measure of protection to the average citizen and to his family against the loss of a job and against poverty-ridden old age. . . .  This law, too, represents a cornerstone in a structure which is being built but is by no means complete (emphasis added).

Franklin Delano Roosevelt

Remarks at presidential signing of Social Security legislation - August 14, 1933

Passage of the Affordable Care Act (ACA) - Obamacare – in December 2009 was by the slimmest of margins and the program remains a contentious political issue. Moreover, the program continues to undergo significant changes through actions taken by the Obama administration, Congress, and the Supreme Court. As Mr. Obama himself noted in April 2014, “Like every major piece of legislation -- from Social Security to Medicare -- the law is not perfect.  We’ve had to make adjustments along the way, and the implementation . . . has had its share of problems.”

But today should remind us that the goal we set for ourselves -- that no American should go without the health care that they need; that no family should be bankrupt because somebody in that family gets sick, because no parent should have to be worried about whether they can afford treatment because they’re worried that they don’t want to have to burden their children; the idea that everybody in this country can get decent health care -- that goal is achievable. 

Critics – and the program has more than its share – may note that the cost of achieving that goal is significant, especially with the announcement of October 24, 2016, that premiums under ACA will rise on average by 22 percent on the heels of an 11-percent increase in 2016.

Here, however, we do not address costs; instead, we accept that however much ACA may change the fact remains that the American health care system will continue to evolve in ways that affect all of the health care professions as well as the preparation of health care professionals. Accordingly, we heed the advice of that noted expert on health care, Wayne Gretzky, and urge the leaders of universities, academic health centers, and schools of medicine, pharmacy, and nursing to – 

• worry somewhat less about what is happening now and more about where the course of change is taking health care,

• continue, in the words of the Blue Ridge Academic Health Group, “synchronizing the academic health center clinical mission and education mission in changing environments”, and 

• while acknowledging ACA will continue to change, nevertheless anticipate the broad outlines of a comprehensive, compulsory national program of near-universal health care insurance and align their education and training as well as aspects of research agenda to those outlines.

In short, skate to where the puck is likely to be.

And what are some of those outlines and parameters?

Care and treatment will become much more patient-centered. Everyone in health care thinks she and he is focused on the needs of the patient, just as most people who work for universities see themselves as concerned primarily with students and their needs. But colleges and universities and hospitals, clinics, and health care centers often operate on the basis of protocols, procedures, and logistics that actually better accommodate in-house priorities over those of the people who seek out services from those organizations. Whatever else may change in health care, it seems certain that care and treatment will take place more on terms the patient establishes. This includes delivering treatment in settings other than and, in some cases, very different from a physician’s office and a hospital.

Preventing illness and injury will assume much greater importance than dealing with the consequences of sickness and accident, particularly as what is known about individuals in terms of genetic predilection continues to grow and be understood. Indeed, personalized medicine and care will become realities as will behavioral interventions to pre-empt maladies to which a patient is known to be predisposed.

For such intervention to be effective, more cooperation and collaboration within health care settings and among the health professions, on the one hand, and beyond to other institutions and organizations will, on the other hand, become necessary and the capacity to work with persons and organizations in addition to health care ones will take on more importance. Even if “population health management” remains an elusive concept to define with precision, its relevance is already growing and requiring working with agencies and services once viewed as important but outside the province of health care proper.

Patient outcomes and their relative value instead of effort and medical inputs will place a higher premium on diagnosis and efficient use of resources than is already the case.

On the fiftieth anniversary of social security’s creation its then-acting Commissioner noted that the program came about as a response to the plight of the elderly in the Depression.

The Social Security program of the 1980's is the direct descendent of the limited program of contributory old-age benefits enacted in 1935. The program, which today covers virtually all jobs, continues to have certain basic characteristics found in the original program; that is, eligibility is earned through work in covered jobs, participation is generally compulsory, the amount of the benefits is related to covered earnings, the program is intended to provide a base of protection, and benefits are financed primarily through dedicated payroll taxes paid by workers and their employers.

More recently, calls for alternatives to social security, usually its privatization, suggest that even national programs with long histories are subject to challenge and debate. The Affordable Care Act will be no exception.

But the popularity of such programs and the clout of their stakeholders make it likely that those programs will endure, albeit, changed. Indeed, Medicare and Medicaid are expansions of the original social insurance program.

It therefore seems prudent for those who are charged with preparing the professionals for such programs as created by the ACA to continue to adapt and, to the greatest extent possible, anticipate what appear to be nearly inevitable changes to such programs.




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