The fickle attention of political pundits has shifted of late from health care reform to budget cuts and labor union protests. But as the Patient Protection Affordable Care Act (known as “Puh-Paca” or the ACA in medical circles) nears its first birthday, much of the real drama is just beginning. Because its changes were designed to roll out slowly over 4 years, many people have not yet directly felt the effects of the ACA in their lives. But the primary players in American health care, including insurance companies, hospitals, and doctors, have been scrambling to guess where they will find their footing in the new medical landscape. That isn’t easy, Jeff Goldsmith warned in his MacLean Center for Medical Ethics seminar, as the future landscape remains in unpredictable flux.
In the late 70’s and early 80’s, Goldsmith worked at the Medical Center as Director of Planning and Government Affairs and Special Assistant to the Dean of the Pritzker School of Medicine. Now he runs Health Futures, a health care consulting firm, and frequently writes and speaks on the changing world of health care. As you might expect, Goldsmith is pretty well-versed in the gritty details of the ACA, having read the entire 2900 pages of the legislation twice, he said.
“The depths of my masochism now stands revealed to you all here in public,” Goldsmith joked. “I’ve become a Talmudic scholar of this legislation.”
Now that he is well informed about the content of the act, Goldsmith’s critical assessment was a pretty firm thumb’s down – not as a partisan, but as a policy analyst. Goldsmith criticized the delayed activation of many of the act’s effects, arguing that spacing them out over two election cycles made it vulnerable to repeal if power shifted in Washington (as it started to in 2010). Though reducing medical costs was touted as a priority of the bill, the legislation does “nothing meaningful” along those lines, he said. And by expanding Medicaid and placing additional financial burden upon already struggling state budgets, the reforms may threaten the bottom line of hospitals who depend upon government reimbursement for treating patients on public insurance.
“We’ve taken an enormous fiscal risk, and it could turn out great, or it could turn out terrible,” Goldsmith said.
But many of these worst case scenarios are dependent upon how the legislation is implemented and whether new models of care and payment can be designed – quickly. The act gives the Centers for Medicare and Medicaid Services $1 billion a year (up from $30 million a year) to evaluate new ideas for delivering health care more efficiently and at lower cost. That’s one area where academic medical centers have the power to step up and steer the future of health care through programs like Healthcare Innovation Zones, Goldsmith said. The emphasis on cutting-edge research and the integration of clinics and hospitals at academic centers should also be an asset as the healthcare rules begin to shift.
“I think academic institutions have numerous strengths that give you a capability to respond that doesn’t exist in non-academic places,” Goldsmith said. “I think both the meritocracy and the reverence for science that pervades these places are a plus in environments where you have to begin making choices about what care people receive.”
But while the ACA as written will present many challenges to academic medical centers and other healthcare players, Goldsmith argued that the success of Republican threats to repeal the new laws would be even more harmful. In an environment of budget cuts and belt-tightening, many of the “safety net” programs provided by the federal government for the sick and impoverished could be left without adequate funding, producing increased strain on hospitals that serve those populations with no plan (however flawed) for improvements in the system.
“It doesn’t matter who is President, it doesn’t matter who signed this bill into law; if this bill is repealed, if those coverage expansions do not take place, these institutions will be the largest single losers in our entire society,” Goldsmith said.
[Each academic year, the MacLean Center for Clinical Medical Ethics organizes a series of lunchtime seminars by physicians, biologists, economists, social scientists and other experts covering the biggest questions in health care and ethics. This year’s theme is “Health Disparities: Local, National, Global,” and the series was put together with the Urban Health Initiative, the Global Health Initiative, and Finding Answers. ScienceLife will carry regular coverage of this unique series, and video of the lectures will be posted when available.]