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Affordable Care Act has rocky road ahead despite Tavenner confirmation

May 21st, 2013

by Kent Bottles

The 91-7 confirmation by the U.S. Senate of Marilyn B. Tavenner as administrator of the Centers for Medicare & Medicaid Services means we now have a permanent CMS leader for the first time since Mark B. McClellan, M.D., left the post in October 2006.

Republicans refused to allow a vote on Obama's first choice, Donald M. Berwick, M.D.; he served as acting administrator for 18 months under a recess appointment.

Does this bipartisan Senate vote mean we have finally accepted that the Affordable Care Act is the law of the land? Will all Americans now work together to ensure the new law will be fully implemented as smoothly as possible?

In a word, the answer to those questions is no.

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For example, one of the senators voting against Tavenner was the Republican Minority Leader Mitch McConnell who issued the following statement to Politico:

"By giving the CMS administrator the primary role in implementing Obamacare, with the responsibility for issuing and enforcing thousands of pages of new regulations, rules and requirements, the Obama administration has changed the central focus of this job. The new administrator's time and focus will be diverted on what my Democratic colleagues have called an impending 'train wreck,' rather than strengthening Medicare and Medicaid at a time when they face enormous challenges."

Democratic Sen.Tom Harkin of Iowa delayed the Tavenner confirmation vote to protest the raid of ACA's prevention and public health fund to pay for implementation costs.

In the same week that Tavenner won confirmation, the GOP dominated House of Representatives voted for the 37th time to repeal the ACA even though there is not a chance the Senate will agree or that President Obama would sign such a law.

The American public also is confused about the ACA. The Kaiser Family Foundation's April poll found that four in ten Americans are unaware that the ACA is still the law of the land. Among groups specifically helped by the health care law, the findings are even more worrisome: six in ten households earning less than $30,000 a year and less than half of young people are unaware that the ACA has not been repealed.

These findings led a New York Times columnist to conclude, "A clueless electorate is a corruptible one, and one that seems ill poised to make the smartest, best call about something as sweeping as Obamacare and how it gets tweaked or not down the line. Maybe we'll blink our way to the right decisions. Or maybe we'll just stumble around with our eyes closed."

Does all of this mean implementation of the ACA will be a total failure? Probably not. It will work in some states; it will be messy in some other states.

As I mentioned in my Hospital Impact blog post right after the presidential election, most of the action has shifted from Washington, D.C., to the states, where much of the implementation must occur. I discussed Oregon's ambitious coordinated care organization approach to Medicaid and South Carolina's close collaboration with private companies.

Another unique state approach to the ACA has surfaced in Utah, where Gov. Gary Herbert and U.S. Department of Health & Human Services Secretary Kathleen Sebelius have agreed to have a preexisting state unit become the exchange for employers with 50 or fewer employees and the federal government will set up an exchange for individuals.

Maryland has been a states that enthusiastically embraced the ACA from the beginning, and with its recent announcement of a sophisticated public relations connector campaign it likely will have a smooth implementation process. Another state that has proactively embraced the ACA is Vermont, where Act 48 established the Vermont Health Benefit Exchange and where exchange insurance premiums have come in lower than predicted by many experts.

In contrast to states like Oregon, Utah, Maryland and Vermont, where citizens may encounter well organized approaches to ACA implementation, Texans may well experience more difficulties because Gov. Rick Perry has consistently opposed state-run exchanges and the expansion of Medicaid.

On Perry's website, he states, "If anyone was in doubt, we in Texas have no intention to implement so-called state exchanges or to expand Medicaid under Obamacare, I will not be party to socializing healthcare and bankrupting my state in direct contradiction to our Constitution and our founding principles of limited government."

The Washington Post
recently published a fascinating summary of articles from 1966, when Medicare was first introduced:

"What will happen then, on that summer day when the federally insured system of paying hospital bills becomes reality?" Nona Brown, a New York Times reporter, wondered in a story published April 23, 1966. "Will there be lines of old folks at hospital doors, with no rooms to put them in, too few doctors and nurses and technicians to care for them?"

Most of the articles, like those written today about the ACA, emphasize the difficulties of enacting Medicare because it represented such a sweeping change. Today 47 years later, anyone who wants to change Medicare is met with stiff opposition from the public who largely feel entitled to their Medicare benefits.

Tavenner's confirmation as CMS administrator is a welcome bipartisan episode that seems to be out of step with most of the reaction to the ACA. The American people's experience of the ACA will be mostly decided by where they live. There will be some places where I predict it will be a smooth transition. There will be other places where it will most likely be a rocky time.

Hopefully, the nation can learn from what works and what does not work in making changes to this vital industry that represents one fifth of the U.S. economy.

Kent Bottles, M.D, is a Senior Fellow at the Thomas Jefferson University School of Population Health.

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