Halleluiah! The ACA is Constitutional!


June 28, 2012

ACA is Constitutional!

Halleluiah! Halleluiah! Hall-e-lu-iah!

The Court has affirmed the Individual Mandate as a tax! The Court has supported the Medicaid Expansion!

Clearly, the Supreme Court has followed some key principles enshrined in our defining national documents. Our Declaration of Independence seeks independence in order to “promote life, liberty, and the pursuit of happiness.” The preamble to our Constitution seeks to “promote the general welfare.” Promoting life, the pursuit of happiness, and the general welfare are intimately related to good health: none are achievable without it. Hence, a very strong basis exists in the earliest documents of our country for our national government to become engaged in actions that promote the good health of all Americans.

The 14th Amendment to the Constitution guarantees equal protection under the law for all Americans. A restatement of this protection is “we value all people equally.” This is a clear basis for the dictum of social justice in our civic life. In health care, this can be interpreted to mean that our national government has the obligation to undertake efforts to reduce health disparities by actions that promote and maintain equity.

When we combine the principle of good health as a basic concept and the dictum to promote equity, we have a very, very strong basis for arguing that our national government must undertake national health reform efforts to foster the conditions under which life, happiness, and the general welfare can actually be pursued. In fact, it is precisely to promote these goals that the United States of America was formed originally. We have strong reason to celebrate this July 4th!

Now, we must press ahead with core reforms in care delivery that are already underway. Catalyzed by the affirmation of the Affordable Care Act (ACA), these reforms will be key to the nature of the care delivery system that is taking shape now. These reforms certainly will be with us as we prepare to move into the third decade of the 21st Century.

The principal foci of the ACA are coverage and access. In fact, both features of the Supreme Court Case—individual mandate and Medicaid expansion—are about these issues. The ACA gives much less attention to the actual configuration of care delivery going forward. Yet, a few moments reflection will help you realize that health reform can be done by insurance expansion and care reconfiguration. Here, I would like to explore care reconfiguration a little further.

By care reconfiguration, I mean how we approach service delivery, who delivers the care, how we combine our organizational resources, and how we allocate our available dollars. At the moment, all are in rapid flux. Here, I would like to explore the rugged landscape of these changes, which are typically done quietly. Included are:

Movement toward Whole Health and Person-Centered Care. Most administrators realize, at least intuitively, if not operationally, that care of the whole person in a single place is both more effective and less costly than piece-meal care delivered by separately organized programs. Thus, the pace of is accelerating, like snow in an avalanche. Some organizations are purchasing others, new inter-organizational arrangements are emerging, some hospitals are purchasing others, other hospitals are partnering with primary care practices, and other primary care practices are working closely with community entities. These consolidations are likely to result in better quality integrated care, with overall cost savings per person served.

Similarly, health administrators now recognize that care providers have a major role to play in disease prevention promotion. Like whole health, this realization is producing tumultuous changes in the actual care that is being delivered. What would have been thought to be virtually impossible just a short time ago is now commonplace: wellness clinics are emerging, healthy promotion groups are becoming common, and people are taking personal responsibility for their own health. Administrators now realize that prevention and promotion are part of care delivery. In fact, we are in the early phases of a major social movement.

Movement toward Peers as Health Navigators and Care Supporters. Another quiet revolution is the rapid growth of peer workers in the healthcare settings. It already is well documented that peer support improves recovery from behavioral health conditions. Less well explored is the role that peers can play in helping to navigate the broader healthcare system. For example, anecdotal evidence suggests that peers placed in emergency rooms can reduce dramatically the inappropriate use of this setting by persons with behavioral health conditions.

To facilitate these positive developments, we will need to train peers to perform navigation and support functions in integrated care and other health care settings. Clearly, peers will need a set of core competencies that transcend these settings, and other competencies that are situations specific. We must undertake this training as soon as possible.

Movement toward Management of Benefits. As we go forward, it is very clear that management of benefits will become ubiquitous. However, unlike in the past, benefit management will occur through case and capitation rates that are performance adjusted, rather than through external review. A case rate is based on cost per person served; a capitation rate is based upon the cost per person in a population, whether or not services are received. Over time, as we develop better procedures to manage the health of populations, I suspect that we will be transitioning from case to capitation rates. A clear national goal by 2020 is to manage both Medicaid and Medicare using one or the other of these financial arrangements.

Right now, we can begin to prepare for these far-reaching changes. We need to examine current systems that employ case or capitation rates to determine how they operate, how staff are trained to use them, and what issues are associated with their use. We also need to examine our current financial systems to determine whether they include sufficient information on specific services and specific patterns of service use actually to derive case or capitation rates.

Movement toward Linkage of Social Services. Most public clients require one or more social services—job supports, housing supports, or social supports. Absent these supports, health care services are less effective. Hence, major efforts are underway in Washington DC to maintain funding for these services and to help policy makers understand how important they are to the success of health services. As we go forward, it is very like that health homes will be expanded to include these services, and that they will be reported as a part of the electronic medical record.

To prepare for these changes, we need to improve our linkage with social service providers, develop a more in-depth understanding about how they can be linked to health services, and explore potential linkages between health records and social service records.

Looking Ahead. Thus, we have a huge behavioral health agenda going forward. You may wish to undertake internal planning for these changes, as well as strategy discussions about the new partnerships that will be necessary to implement them.

In sum, all of these developments will help us serve more people, with better quality services and outcomes, with the funds that are currently available thanks to the Supreme Court. This is all very good news indeed.

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