Thursday, April 28, 2011

NEJM - Remaking Health Care

The April 28th issue of the New England Journal of Medicine contains a series of papers on Health System Reform:

Consensus and Conflict in Health System Reform — The Republican Budget Plan and the ACA
Timothy Stoltzfus Jost, J.D.

The “Roadmap for America’s Future,”1 put forward by Representative Paul Ryan (R-WI) and adopted in principle as the Republican budget proposal for 2012, offers a vision of the role of government and the nature of a good society that contrasts sharply with the vision inherent in the Affordable Care Act (ACA). Nevertheless, the Roadmap and the ACA have much in common, suggesting that there is a growing consensus regarding the way in which the U.S. health care system should be structured. The Republicans have borrowed ideas from the ACA, and the ACA drew heavily on earlier Republican proposals. Exploring the shared elements of the two plans (see Similarities and Differences between the Affordable Care Act and the Ryan Plan) to clarify the extent to which consensus has emerged in U.S. health policy may enable us to begin addressing the serious conflicts that remain.

Reforming Medicare — Toward a Modified Ryan Plan
Gail R. Wilensky, Ph.D.

Medicare reform, an issue that is rarely out of the political spotlight for long, has once again achieved a position of prominence. The current focus is primarily on the role that Medicare and other entitlement programs play in driving up the deficit, but the need to reform Medicare long predates the economic collapse of 2008.

High-Risk Pools — Merely a Stopgap Reform
Linda J. Blumberg, Ph.D.

A central goal of health care reform is to ensure that everyone, regardless of health status, has access to adequate, affordable insurance coverage and medical care. The Affordable Care Act (ACA) aims to achieve this goal by prohibiting insurers from engaging in practices that discriminate against the sick and requiring that the vast majority of Americans have insurance coverage — allowing the costs of care for people with substantial health care needs to be shared broadly by the whole population. Because most people are healthy at any given time, the sharing of expected health care costs should mean only small increases in premiums for the healthy and large savings for people who may incur disproportionately high medical expenses. However, these broad-based reforms will not be implemented until January 1, 2014.

Medicaid at a Crossroads
John K. Iglehart

Approximately 68 million Americans were enrolled in Medicaid at some point during 2010, when the program spent $406 billion on acute and long-term care services for its beneficiaries.1 Another 16 million people are slated to gain Medicaid eligibility through the Patient Protection and Affordable Care Act (ACA), which would make the federal–state program responsible for financing services for more than one in four Americans. Enacted in 1965 as an afterthought to Medicare, Medicaid has become a vast public enterprise that underscores the limits of the private insurance market even as it squeezes state budgets already stretched by the recession. These realities, along with the fact that an increasingly conservative electorate has given Republicans control of the U.S. House of Representatives, raise a fundamental question for policymakers: What level of support should government provide to people who can’t afford private insurance and are not offered employer-sponsored coverage?

How Not to Reform Medicare 
Henry J. Aaron, Ph.D.

Medicare reform has become a hot political issue. The program is wildly popular but expensive. It is the principal source of projected increases in budget deficits. With deficits increasingly seen as a mortal economic threat, many believe that now is the time for Medicare reform.

The reform flavor of the day is “premium support.” What is it? What are its strengths and weaknesses?

The ACO Regulations — Some Answers, More Questions
John K. Iglehart

Recognizing that physicians allocate most of our health care resources, Congress and the Obama administration challenged doctors in the Affordable Care Act (ACA) to develop more accountable, quality-driven health care delivery systems, promising performance bonuses for those who succeed. The vehicle that Congress created for tackling this task is the accountable care organization (ACO), which is built on a strong foundation of primary care.1 To qualify as an ACO, a group of health care providers must have the capacity to deliver the full continuum of care to at least 5000 Medicare beneficiaries and to be held accountable for the costs and quality of their care. Although the law links ACOs to Medicare, the administration has encouraged private health plans to contract with these new organizations as well. With the launch of ACOs, the reform law raises new issues that are certain to roil relations between primary care physicians and specialists. Managing care utilization more efficiently could require a rewiring of long-standing referral and hospital relationships. And conflicts may well arise over how to divide ACO savings, with primary care doctors, whose incomes are appreciably lower than those of most specialists, striving to reduce that differential. The implications for hospitals could also prove profound, given the complex new equation for calculating shared savings under the ACA.

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