K. Davis, Realizing the Potential of Health Reform, The Commonwealth Fund, October 2010.
The landscape of American health care has changed dramatically since the Patient Protection and Affordable Care Act was signed in March 2010. Federal and state agencies, the health insurance industry, and others are taking the first steps toward achieving the three goals President Obama set forth when Congress began crafting reform legislation last year:
Over the course of the heated debate leading to the health reform bill's passage, Congress dealt with many difficult political issues: whether to include a public plan, how to regulate the health insurance industry and make coverage affordable, how to control Medicare costs, and how to finance reform. As these critical decisions were being made, The Commonwealth Fund produced a steady stream of timely, on-point research and analysis, while our staff lent their considerable expertise whenever called upon.
Once the law passed, the Fund quickly marshaled its resources to help realize the potential of the comprehensive health reform by: helping health care leaders and the American people understand the changes and what they mean for them; informing implementation of the reform package and assessing its potential to move the United States on a path to a high performance health system; and laying the groundwork for future health care delivery system reforms and health policy action.
Given the law's scope and complexity, its potential is not yet assured. Success will depend on all parties coming together to put the pieces in place, as well as on careful oversight and tracking of health system performance. It will also be important to swiftly apply new knowledge gained as innovations are tested, so that best practices and models can be spread throughout the health system.
Some of the long-term questions that need to be addressed as experience is gained include:
The following essays, published on The Commonwealth Fund Blog over a one-year period, take readers on a journey through the busy months leading to the passage of this historic law and the first stages of its implementation.
What Is Affordable Health Care? reviewed the affordability provisions in the three versions of the bill under consideration at the time: those proposed in the House of Representatives, the Senate Committee on Health, Education, Labor, and Pensions (HELP), and the Senate Finance Committee. Parsing the bills' differences in approaching Medicaid program expansion, essential insurance benefits, and cost subsidies for low- and moderate-income families, this essay stressed the importance of "reaching consensus on what constitutes affordability and committing the necessary funds to achieve it."
Why Health Reform Must Counter the Rising Costs of Health Insurance Premiums also tackled affordability, looking at how dramatically premium inflation has outpaced wage increases over the last decade. Citing Commonwealth Fund and Congressional Budget Office analyses, I observed that offering a public health insurance plan, alongside private plans, to all individuals and employers is our most effective weapon in combating health care costs. The essay also considered other cost-containment options, such as a mechanism for negotiating provider payments under all plans—public and private.
The Costs of Failure: Economic Consequences of Failure to Enact Nixon, Carter, and Clinton Health Reforms made a powerful case for reform by examining trends in health spending over the past 50 years. The analysis showed that if health reform measures proposed by previous presidents had been enacted and succeeded in slowing spending growth by as little as 1.0 or 1.5 percentage points annually, spending trends in the U.S. would have been closer to those seen in other major industrialized countries. Moreover, fewer adverse health consequences and economic burdens would have been borne by American families, businesses, and government.
In addressing the stagnation of health plan quality, Commonwealth Fund Senior Research Advisor Douglas McCarthy suggested in Committing to Improvement in All Areas of Health Care that this plateau might "reflect the limits of what managed care plans can achieve without integration of care delivery and support for physicians and patients in improving quality, as well as the absence of a broader commitment to public reporting and improvement."
In Health Reform: Insights from Around the World, Fund Senior Vice President Cathy Schoen, Vice President Robin Osborn, and I discussed how the health reform debate has been informed by health systems in other countries. With a Commonwealth Fund survey of primary care physicians in 11 countries finding U.S. shortcomings in access, quality, health outcomes, and value, we called for national leadership to make needed reforms in insurance coverage and health care delivery.
National Leadership to Achieve a Performance-Driven Health System called for developing a set of national performance goals and improvement targets, along with supporting policies, resources, and actions. The essay also recommended that the President issue an annual report to Congress on the state of health system performance.
Published at a time when headlines were focused on discord in Congress, Forging Health Reform Consensus highlighted the marked similarities to be found across the three House and Senate reform bills—namely, more choices, greater incentives for accountability, increased transparency, shared responsibility, a redirection of resources, and new opportunities for learning and acting as reform is implemented.
The Way Forward with Health Reform addressed some of the misleading claims concerning the impact of health reform and the lack of understanding of its potential to improve patients' experiences.
In A New Era in American Health Care, Vice President Sara Collins, Ph.D., and I celebrated the passage of comprehensive health reform legislation and outlined the ways it will increase access to needed care, provide new benefits, and slow health care spending growth, as well as test new ways of paying health care providers to improve quality.
Who Is Helped by Health Reform? reviewed how different groups will benefit from the new coverage options, benefit standards, and insurance market rules. An accompanying essay, How Will the Health Care System Change Under Health Reform?, discussed a host of lesser-known provisions that, together, will place new emphasis on preventive and primary care and reward quality.
As these final essays suggest, The Commonwealth Fund has already embarked on its new goal of helping the country realize the potential of reform. Guided by the foundation's mission to promote a high-performing health system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, we have reorganized our research programs to better enable us to address emerging issues in this new era in American health care.
The Fund's programs are now organized into four key areas: Delivery System Improvement and Innovation; Health Reform Policy; Health System Performance Assessment and Tracking; and International Health Policy and Innovation.
Within the area of Delivery System Improvement and Innovation, the programs on Health System Quality and Efficiency, Patient-Centered Coordinated Care, and Picker/Commonwealth Fund Long-Term Care Quality Improvement aim to advance the adoption of promising approaches for improving the quality and value of health care services. The Fund will also promote delivery system models that provide population-based, patient-centered, accountable care that is integrated across the full continuum of services, as well as the underlying payment reforms.
Health Reform Policy, which encompasses the Affordable Health Insurance, Payment and System Reform, Federal Health Policy, and State Health Policy and Practices programs, will address health reform policy options at the federal, state, and local level. Together, these programs will foster the identification, development, evaluation, and dissemination of policy solutions that expand access to affordable, high-quality, and efficient care, particularly for vulnerable populations, while reducing the growth of health care spending.
The projects within Health System Performance Assessment and Tracking focus on comparing health system performance, evaluating and monitoring access to care and patients' reports on the quality of their care, and monitoring delivery system change. This work includes the Fund's national and state scorecards on health system performance, an upcoming long-term care scorecard, analyses of international health system data, and WhyNotTheBest.org, a Web site that offers comparative information on health care provider performance. The Fund also conducts surveys in the U.S. and across countries to provide data that can inform health reform implementation.
Similarly, International Health Policy and Innovation aims to: benchmark U.S. health system performance on costs, quality, access, and efficiency against that of other industrialized countries; understand the lessons to be learned from other countries' experiences in reforming their health care delivery and financing systems; and showcase international innovations that may be relevant to health reform implementation in the U.S.
Along with the Fund's Commission on a High Performance Health System, the integrated research and analysis that will be conducted within our new programmatic structure will help government agencies, payers, providers, and patients as the country moves toward achieving the goals embodied in the Affordable Care Act.