O’Neil, E. (2015). Looking Back Through the Glass Darkly. Solutions 6(2): 12-15. https://thesolutionsjournal.com/article/looking-back-through-the-glass-darkly/
Envisioning
Looking Back Through the Glass Darkly by Edward O’Neil
This article is part of a regular section in Solutions in which the author is challenged to envision a future society in which all the right changes have been made.
T
he changes began to appear in the final two quarters of 2014. By mid-2015, the movement to increase access to health insurance seemed established enough to appear to be a trend. Some of these developments were publicly reported: percentage of lives covered overall, numbers accessing coverage through the exchanges and trends that seemed to indicate that costs were holding constant, and if not, then perhaps bending away from increasing. There was active discussion over validity, meaning, and, of course, causality. Were these developments a function of the Accountable Care Act (ACA) or a reflection of a deep recession followed by a fairly long-running recovery? Other changes were less obvious to the general public and too small to account for a trend: a large delivery system in the Midwest reporting that after three years, over half of new appointments were being made online and that consumer satisfaction with its service was up 22 percent; a major East Coast medical school’s OB/ GYN department announcing that by 2020 it planned to have 80 percent of its births assisted exclusively by a nurse midwife; and, a large medical group in California incorporating a collaborative approach between primary and specialized care, coupled with advance directives and palliative
care as it improved the quality of endof-life experiences for patients and their families. The system was so large—comprising almost 20 percent of the nation’s productive effort—and famously segregated into silos governed by a complex and at times conflicting set of state and federal regulations and funding, that it was hard to see that the policy changes of universal coverage, global payments to providers, and consequences for outcomes that had been established with the ACA had
On the heels of this ruling that was, in the end, seen as more technical than landmark, many Republican-dominated states began to acknowledge that their fiscal and physical health could only be addressed by using a revived and restructured Medicaid program to provide universal coverage in their states. Without such a state policy in place, they would be trapped supporting the old variegated and disconnected arrangements for care that were increasingly expensive and produced inferior outcomes. The contrast to those states that covered nearly all of their citizens through revamped insurance markets and subsidies became increasingly stark.
Many other parts of health care delivery were deregulated because now, a single oversight body could more effectively guarantee performance and public protection.
been deeply, if not perfectly, aligned with the broader changes that were driving themselves through society. These changes included an aging population, growing consumer demand for more control and responsibility, anxiety over the cost of care, and dramatic changes in work and life driven by information technology. The alignment between these two pivotal changes was producing the synergy needed to rework the system from the bottom up, not to dictate the changes from the top down. With a pending Supreme Court review of the legality of subsidies from states without their own purchasing exchanges in mid-2015, Chief Justice Roberts again voted with the majority to sustain the efforts of the essential reforms.
12 | Solutions | March-April 2015 | www.thesolutionsjournal.org
As the economic and health advantages of integration became more obvious, several states realized that the regulatory infrastructure that had been built up around health and health care no longer served the interests of their citizens. These states were the first to experiment with a new structure that looked at finance, delivery, and population health with policy, operational, and oversight dimension in each area. The states could then set health goals tied to outcomes and effectively focus all public and private resources on meeting these goals. The reduced duplication allowed policymakers to know what worked, allowing them to push for change in the ‘system’ to move along faster.