The answer: The law will build up access to care but may not create more-affordable health insurance for those who already have it, or batten down overall healthcare costs, according to experts in the latest Commonwealth Fund/
Modern Healthcare Opinion Leaders survey.
“They think it was very successful in achieving the goal of improving coverage for Americans. They certainly don't think that health reform will solve all of the problems; some of the issues will need to be revisited,” says Karen Davis, president of the Commonwealth Fund.
Harris Interactive conducted the survey, which focuses on health reform, between Feb. 16 and March 15, so opinions were culled before President Barack Obama signed the Patient Protection and Affordable Care Act into law last month. A second piece of legislation—crafted in the House to modify some provisions of the Patient Protection Act—was signed by the president March 30.
A total of 201 Opinion Leaders from the healthcare delivery, policy and finance sectors participated in the survey, which was the 21st in a series designed to gather opinions from healthcare leaders on timely policy issues.
An overwhelming 88% of survey participants said the health reform act would be “very successful” or “successful” in expanding access to affordable health insurance coverage. Percentages ranged from 92% for those in academia to 76% for those in government, labor and consumer groups.
When it came to cost control, Opinion Leaders weren't as confident that the law would lead to positive results. Only 38% said it would be very successful or successful in improving the affordability of health insurance for people who already have coverage, while 35% said it would be “very unsuccessful” or “unsuccessful.”
Sara Rosenbaum—chair of the department of health policy at George Washington University—is more optimistic. She points to a provision in the law that gives the HHS secretary the power to annually review the rates charged within the state-level insurance exchanges. “It is clearly not going to drop the cost of insurance, but it will make it harder for the rates to keep going up and going up without any check in the system,” says Rosenbaum, who participated in the survey.
Another area that survey participants were concerned about was the effect of the law on overall healthcare spending. Just 35% said the law would be very successful or successful in controlling healthcare costs and not adding to the federal budget deficit, while 42% said it would be very unsuccessful or unsuccessful.
“There is an intrinsic trade-off between greater insurance coverage and cost. The big single driver of cost is insurance coverage. The fact that we can demand goods and services and only have to pay out-of-pocket a small fraction of what these services cost is what drives demand all the way through the system,” says Donald Moran, a survey respondent and president of the Moran Co., an Arlington, Va.-based health policy research and consulting firm.
Healthcare spending accounted for nearly 17% of the nation's gross domestic product in 2009, and had been projected to rise to 21% of GDP by 2020 if no reforms were made.
Given the dimensions of the issue, it is not surprising that survey participants strongly supported measures to rein in costs through payment reform and new models of care, such as accountable-care organizations and patient-centered medical homes.
Consider the percentage of survey participants who said it was “very important” or “important” to include these initiatives in a reform package:
78% were for the creation of a Medicare and Medicaid payment innovation center.
86% were for offering incentives for primary care and patient-centered medical homes.
82% were for accelerating the growth of accountable-care organizations.
Survey respondents not only supported congressional action to control costs but also administrative efforts on the part of HHS. Nearly all—92%—“strongly supported” or “supported” the idea of Medicare and Medicaid reform pilots, and 82% strongly supported Medicaid-waiver programs that allow states to pursue demonstration projects to expand Medicaid coverage or reform payment.
“I think in terms of the underlying healthcare cost problem, which is this issue of bending the curve on healthcare costs, you are talking about a long slog,” Rosenbaum says. However, she also points to a provision in the law that will create an innovation center within CMS by Jan. 1, 2011, as the first step. The center is charged with testing and expanding payment models that both reduce expenditures and maintain or improve quality.
Davis adds that the law also gives the HHS secretary “broad authority to spread effective models of payment throughout the Medicare program” without asking Congress for legislation to do so.
Building new modelsProviders and payers are already testing new payment models, says Thomas Priselac, a survey respondent and president and CEO of Cedars-Sinai Health System in Los Angeles. For example, some insurers bundle physician and hospital payments for organ transplant procedures performed at Cedars-Sinai.
Enacting reform measures is only the first step. Opinion Leaders also were queried about their views on implementation. Overall, they were concerned about whether there are enough human and financial resources available within government to implement the law. For example, 60% were “concerned” or “very concerned” about staffing levels at HHS, and 68% were concerned or very concerned about the adequacy of financing for HHS.
Unease extended to state governments as well: 61% were concerned or very concerned about state resistance to reform, and 79% were concerned or very concerned about the capacity of the states to implement reform.
The Commonwealth Fund's Davis says the Opinion Leaders' apprehension about the level of resources, particularly at the state level, wasn't surprising because of “all of the roles that have been assigned to them under the law.” States will be required to set up health insurance exchanges and expand Medicaid to those at 133% of the federal poverty level, which translates to about $29,300 for a family of four based on 2010 guidelines.
Adding to the concern about adequate resources: big state budget deficits. For example, California “is facing a $24 billion budget deficit. It is impossible to know what the impact will be of closing that budget gap and whether it will have an impact” on the California Health Services Department or not, says Priselac, who also is immediate past chairman of the American Hospital Association.
Another issue that might impede implementation of healthcare reform is an inadequate supply of primary-care providers, with 88% of respondents saying they were very concerned or concerned about the issue. The overwhelming trepidation isn't surprising because primary-care providers would be the foot soldiers in new care models to control costs, such as accountable-care organizations and patient-centered medical homes.
“I think everybody knows we don't have enough people,” Rosenbaum says. But she also says, “I think the legislation focuses a lot of time and energy on workforce and access.” For example, she notes provisions in the law to redistribute unused slots in graduate medical education to primary care and general surgery.
Priselac says it's important to deploy primary-care physicians efficiently. That's one reason why hospitalists take care of many inpatients at Cedars-Sinai, freeing primary-care physicians to focus on office visits.
In the end, survey participants believe that the measures enacted this year are actually a work in progress. Says Priselac, “As this moves forward, there is obviously going to be subsequent legislation and regulation that essentially puts a lot of these things into play.”
A majority of participants assigned high priority to a number of topics to be “readdressed in the next two or three years.” A nearly unanimous 95% expressed concern about the affordability of coverage for low- and moderate-income families, saying it is “important” or “very important” to take another look at this issue.
Cost controls, again, received high marks. Some 89% said it was important or very important to strengthen cost controls, while 79% said it was important or very important to pursue all-payer/provider reform initiatives.
On the other hand, the long-debated public option garnered support from a plurality of Opinion Leaders; 46% thought it was important or very important to take another look at it. Another 29% said a public option was “unimportant” or “very unimportant,” while 24% said it was “neither important nor unimportant.”
As time moves forward, the answer to the question of whether the new health reform law works will depend on the actions of the architects and those laying the foundation of reform—not only legislators and administrators but also providers, according to Priselac.
“There is an opportunity here for doctors and hospitals and everyone involved in the delivery of care to see what we can do to contribute to solving what is, understandably, a significant concern in the country,” Priselac says.
Linda Wilson, a former Modern Healthcare
reporter, is a freelance writer based in McHenry, Ill. Reach her at lindajwilson@comcast.net.
