Anyone who dares make predictions about the future of the U.S. health care system in 2010 is standing on shaky ground. With the passing of the Patent Protection and Affordable Care Act (PPACA)- the legislative product of the health care reform debate – everyone knows that the rules are about to change in this country, but nobody is quite sure how. The changes included in the act will not be fully phased in until 2014, and the complicated business of determining exactly how those changes are implemented is currently underway in the bureaucratic halls of Washington. Throw in the Republican gains in this month’s election – won at least in part on promises to repeal aspects of PPACA – and uncertainty is rampant about the most important overhaul to American health care since the creation of Medicare.
That foggy vision of the future dominated discussion on the opening day of the 22nd Dorothy J. MacLean Fellows Conference, this year’s edition of the MacLean Center for Clinical Medical Ethics annual event. Though the topic of Friday’s sessions was nominally health disparities on the local, national, and global stages, the discussion was magnetically drawn again and again to PPACA, which was designed in part to narrow notorious health care gaps in the United States. The physicians, ethicists, and social scientists at the conference unsurprisingly agreed that it was imperative that those disparities be reduced, but less consensus was reached on whether PPACA would be the magic bullet to do so.
On its face, the legislation makes several sweeping moves that would appear to directly confront health disparities in America. No PPACA component is more significant for underserved populations than the expansion of medical coverage for the country’s 47 million people without insurance, the majority of whom are minorities, said A. Eugene Washington, the dean of the David Geffen School of Medicine at UCLA. The other major aims of the bill, improving quality and reducing cost, may produce more mixed results for disparity reduction, as new payment measures based on outcome, rather than volume, could push health care providers to avoid communities with poor health at baseline. Much relies upon how the broad goals of the bill are truly implemented by federal and state agencies, he said.
“The legislation is really a framework, and it’s going to get shaped,” Washington said.
The (mostly) pessimistic view of that shaping process was provided by Harold Pollack, professor of social service administration at the University of Chicago. Pollack said the legislation, as written, is the most important AIDS and drug addiction policy ever passed in the United States and that expanded coverage will help address some disparities. But he was also critical of the slow roll-out of policies because it makes them contingent upon “bipartisan goodwill,” a scarce resource lately in Washington.
“We’re in for a wild ride, and it’s going to be a wild ride in a time of fiscal crisis and political gridlock in the short run, when the most difficult implementation challenges in our health care system will have to be resolved,” Pollack said.
Pollack also pointed out that coverage for the uninsured and more focus on preventive medicine will help with deaths from cardiovascular disease, but not gunshot wounds. As Norman Daniels, professor of ethics and population health at Harvard University, presented, unequal health is not just a matter of unequal access. “Social determinants,” such as education, socioeconomic status, and crime, also matter, and efforts to address those factors are outside of the realm of the PPACA.
Can those social determinants even be effectively changed? James Heckman, professor of economics at the University of Chicago and Nobel laureate, presented evidence that a basic early-life intervention – education – can have dramatic effects on health later in life. A study of British citizens born in 1970 found that “early life factors” such as education and socioeconomics explained 50 percent of health disparities, guiding people toward or away from health-relevant behaviors such as smoking and maintaining a healthy diet. A study by Heckman and Dimitry Masterov that has tracked a group of black children in Ypsilanti, Michigan for 40 years found that a preschool program improved school performance and employment and reduced crime and teen pregnancy. In economic terms, those preschool classes gave society a 7-10% rate of return – better than investing in the stock market over the same 40-year period.
In light of that success, Heckman said he was worried that health care reform policies have been focused on curing poor health after it appears, rather than snuffing out the social causes of those diseases in the first place.
“It’s sad that the discussion has so much emphasized health care and so little prevention,” Heckman said. “We could have spent the money on early childhood programs. This is one way to bend the curve [of health care spending], to get rid of the problem at the outset.”
Fortunately, PPACA isn’t the only effort to reduce health disparities, it’s merely the biggest. More localized efforts such as the University of Chicago’s Urban Health Initiative (presented at the conference by director Eric Whitaker) seek to address social and neighborhood factors while improving disease prevention and health care access in underserved communities like the South Side of Chicago. But the dent those projects put into overall health disparities across the United States will take place against the backdrop of the federal reforms of the next few years – whatever form they take.
“We have a pretty good idea of what [the health care system] will look like in 2030. What it will look like in 2013, no one has any idea,” Pollack said.
[Coverage of Day 2 of the MacLean Conference, featuring discussions of newborn genetic testing, palliative care, and transplant disparities, will appear later this week.]