Thursday, April 22, 2010

PPACA, The New Health Reform Law: How will it affect the public's health and primary care?

A great deal remains to be done before any of the parts of the new health reform law, the Patient Protection and Affordable Care Act (PL 111-148), begins to affect people. Regulations have to be written, appropriations (in many cases, where they are not included in the law) need to be made (or not). There are a number of lawsuits pending, including several by states’ attorneys general. While these suits probably have little constitutional basis, nothing is certain when it comes in front of a Supreme Court that has recently declared (in Citizens United) that corporations have the same rights as people, at least in terms of giving money to political campaigns. However, it is a good time to look at this bill – at least parts of the massive 2,600 pages – and consider the impact on health, medicine, and social justice.

I indicated in a guest blog piece on Health Strong, “Why we need health reform”, before the bill became law, that the three key problems that exist, and need to be the touchstones to examine for the new law’s effectiveness, are:
1) Access – does it increase access for the 45+ million uninsured, tens of millions of underinsured, and tens of millions more whose premiums, co-pays and deductibles are becoming more and more prohibitive while the extent of their coverage drops?
2) Cost containment – as medical care costs approach 20% of GDP they threaten to choke off other, key social programs. Is there a viable method for cost control?
3) Health -- medical care, and even health care, are not health (Health is more than Medical Care, Jan 10, 2010). The goal must be to improve people’s health, of which medical care contributes only 15 % at best. In addition to genetics, individual behaviors and the socioeconomic environment are better predictors of health than medical care. At a population level, it is arguably true that improving educational opportunity for all children would provide greater increases in health status than all medical care.

The new health reform law will certainly increase financial access to health care for many people, an estimated 32,000,000. To the extent that this improves actual access will depend upon elimination of other barriers including geographic, transportation, co-pays and deductibles for those who are not fully subsidized, the existence of enough providers (especially in primary care) and the ability of people to get to the place where they can be seen (e.g., many people lose a day’s pay if they go to the doctor). The law will also (provided insurance companies can be prevented from “gaming” the system) prohibit denial of coverage for pre-existing conditions (for children this year; for everyone in 2014) and prevent rescissions – canceling your policy when you get sick.

In addition, as I have previous noted (Primary Care and the Medical Home, Today and Tomorrow, Primary Care and Residency Expansion), there need to be doctors or other providers; in particular there need to be primary care doctors. In rural areas, health care means essentially only primary care, and as has been noted by many of these blog pieces by Robert Bowman (Ten Biggest Myths Regarding Primary Care in the Future, Top Ten Reasons for Future Subspecialist Physicians To Be Concerned) and myself, this means family doctors, because this is the only “form” of primary care that “distributes” to where the population is – 20% of Americans live in rural areas and 23% of family doctors practice in such setting; no other primary care form (physician, NP, PA) come close. However, the need for primary care providers is not only in rural areas; in suburban and urban areas people still need a physician who is “their” doctor, not the doctor for only a piece of their body or a particular condition, someone who can coordinate and manage all their preventive, chronic, and acute care. And there are not, as we have also demonstrated, enough of them. Massachusetts discovered this when its statewide health reform dramatically increased the number of state residents with financial coverage; there were not enough primary care doctors to see all these people. We have also discussed the fact that medical students are not choosing family medicine and other primary care specialties in adequate numbers. (Note that our physician workforce is less than 30% primary care and dropping; to get to 50-60%, the ideal ratio in all international studies, in less than a generation, will require more than 50% entering true primary care training.)

What does the health reform law do for these issues, particularly in producing primary care doctors and related issues? Here are some of its components, with page numbers in the law in parentheses for anyone who wants to read the law in more detail:
· Primary care physicians (defined in a reasonable way) will received a 10% increase in reimbursement from Medicare for 5 years, as will general surgeons practicing in rural areas.
· The annual threat to all physicians from Medicare cuts will be addressed.
· Medicaid will reimburse primary care physicians at the higher Medicare rate for 2 years (2013-14).

These changes (pp 1413ff) will help primary care providers survive, but are not likely in themselves to reverse the trend of students entering subspecialties. (The American Academy of Family Physicians, AAFP’s, Robert Graham Center (“Does graduate medical education also follow green?”, ref below) estimates that a 35% increase in primary care reimbursement would be needed for students interested in family medicine to feel that they would earn enough to be able to pay off their medical school debts). In addition, residency training is addressed in several ways:
· Unused residency “slots” (positions Medicare would pay for) are to be distributed with a preference for primary care and rural training (pp 1421ff),
· Medicare GME money would pay for training in non-hospital settings, addressing the problem of hospitals wanting to keep residents in-house and thus limiting their training in community settings (pp 1431ff),
· Teaching Health Centers, especially in federally-funded Community Health Centers, would be encouraged with grant money (pp 1457ff).
· Training grants for primary care (“Title VII”) will be re-funded, and there will also be new grants, both with specific funding priorities rewarding schools and residencies that send graduates into underserved and rural areas (pp 1315ff, pp 2343ff), as well as grants to fund Preventive Medicine residencies (pp 2349ff).

Access to care will also be enhanced by large increases in funding for Community Health Centers (CHCs) (pp1479ff) and for loan repayment for doctors who work in underserved areas through the National Health Service Corps (NHSC). It will also provide funding for the creation of Primary Care Extension Services, which I have previously advocated (pp1404ff). The Medical Home concept, which identifies a multi-disciplinary “home” for each patient, requires advanced management techniques like electronic medical records and easy patient access, and pays for prevention and care coordination, is supported through an “Innovations Center” and the law requires payment for these services from insurers (p 2048). Funding is also provided for national and state health care workforce planning. In addition several new programs, including one that creates US Public Health Service “scholars” who will receive tuition and stipends (pp. 1372ff), and a major initiative to train dental therapists to provide basic dental care in areas where there are no dentists or even dental hygienists, are included, as are demonstration projects to reduce fees for underserved people (pp. 2357ff), and training Community Health Workers (pp. 1346ff).

On the downside, more than 23 million people, including all undocumented residents will remain uninsured. Clearly, covering the undocumented is a “hot button” political issue, but not allowing it is a classic example of “head in the sand”; these people are here, they work, they pay taxes – and they get sick and use expensive emergency rooms for care of conditions that could have been treated much earlier and better. The law is also a windfall for both insurance companies (who will get paid at their outrageous rates for all these new customers) and pharmaceutical companies. There are no structural systems for really controlling costs.

In summary, the good parts of the new law are that it is good for primary care practice, probably good for providers in general, expands funding for primary care education, provides more funding for CHCs and the NHSC, creates funding for Medical Homes, Primary Care Extensions, and other innovative programs. More people will be covered, it will prohibit denying coverage for pre-existing conditions and prevent rescissions, and will create restrictions on “medical loss ratio” – that is, insurers will have to pay at least 85% of the premiums they collect on actually paying for health care (imagine that!).

On the negative side, it leaves lots of people uninsured, is very complicated (it phases in over many years and it is still not clear how – or even whether – all the components will be implemented), there is no real mechanism for cost control, and it is good for insurance companies and good for drug companies (a bad thing – e.g., Insurance company greed: To know them is to not trust them). It also creates incredible complexity in coverage, with different members of families likely being eligible for coverage through different programs.

We will see how this plays out, but it would have been (and still remains) a much better idea to simply include everyone into Medicare, creating a single payer for everyone, a simpler and much less costly administrative mechanism, and a real opportunity to control costs. Those, including most (or all) Republicans who are critical of this bill because of the cost are neither advocating (in fact, they desperately oppose) a single-payer system that would really save money, nor even recognizing that continuing the way we were going was about the worst choice. Maybe it is too much to ask them for logical consistency. But those of us who are committed to social justice must continue the struggle. Re-read Dr. Ferrer’s blog piece The Sharp End of Ideology.

· The bill – HR 3590
· MEFS summary
· Community Catalyst summary
· Kaiser Family Foundation summary
· STFM Summary & implementation timeline
· Implementation timeline (AAFP)
· Aaron HJ, Reischauer RS, “The war isn’t over” NEJM, 8Apr10;362(14):1259-61
· Himmelstein DU, Woolhandler S, “Obama’s reform: no cure for what ails us”, BMJ 3April2010, 340:742
· Weida NA, Phillips RL Jr, Bazemore AW. Does graduate medical education also follow green? Arch Intern Med. 2010 Feb 22;170(4):389-90

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