Pressures Mount for ACA Reforms or Revisions

Commonwealth is making a pitch for ACA indicating that there could be repercussions that could prevent it from being repealed. There are many reasons to think that there could be repeal or major changes.
  • Election results
  • Replacement of HHS leadership
  • Mixed reviews of ACA by the American people and patients and providers
  • Lack of significant reform due to ACA compromise (not universal, not single payer, not drug cost interventions)
  • Lack of improvement for primary care and basic services and failure to rein payments for highly specialized care (with continued workforce distortions)
  • Continued promotion of health insurance coverage as a great advance despite the inability to consistently get care despite coverage
  • Leaders that cling to all aspects of ACA without regard to its limitations
  • The failure to do appropriate testing of ACA changes on a small scale prior to large scale implementation (with numerous major consequences) 
  • Leaders that have forgotten the lessons of past failed health reforms
Leaders have apparently failed to understand the growing problems of populations with new and costly and confusing insurance, high deductibles, overwhelming Medicaid restrictions to care, constant churn between different plans and practices, narrow networks, and insufficient access.  

Perhaps supporters of ACA have forgotten that those who benefit from ACA are also the least organized and least involved in activities that might result in ACA support.

The History of Major Health Reform Failure 

The history of health reform is brief. It apparently takes 20 - 25 years for pressures to build to the point that any reforms are possible. It appears to be getting easier to torpedo needed reforms. The 2010 key reforms were defeated before implementation. The 1990s reforms took a few years to bypass. It took a bit longer to compromise the original 1965 - 1975 changes, but was distorted to more for fewer at higher cost with limited outcomes as with other reform periods. The powerful have defeated help for the powerless more rapidly. Unfortunately the actions of the reformers have helped to contribute to the defeat of their reforms.

Often important prerequisites were not addressed prior to reform implementation. A most important failure was the failure to understand the need for sufficient primary care.
Managed Care Failures and Insufficient Primary Care/Gatekeepers

Managed care reforms in the 1990s were repealed partly because of insufficient primary care. Privileged and public citizens rallied for repeal because of difficulties accessing specialty care and primary care - because primary care was the gatekeeper to all care.  If you restrict care, people will react.

The smouldering embers of the restrictions were fanned into flames by the corporate and institution and association powers that actually determine our health care design. They whipped up overwhelming support to take out gatekeeping, managed care, and other restrictions to their profits.  

Witness how it was possible to rebrand public option ACA into government control ACA. It helps to have the most resources at your disposal when you want to shape opinions.

There was a bonus for those dedicated to profits due to insufficient primary care. The primary care resentment or backlash post managed care helped to set primary care back in ways from which it has never recovered. Many patients have found other care - more costly care.

Pure and Simple - ACA Failed in Primary Care Delivery Capacity

Primary care was never a priority for ACA. Numerous higher costs via ACA have made matters worse. While there was a temporary boost for primary care payment, the cost within practices to change to slightly better pay then back down to lesser pay after 2 years negated the temporary "better pay." Payments where Medicare and Medicaid patients are concentrated are incapable of boosting access.

Process Design and Implementation Needs Engineers, Not Innovators and Promoters

Engineers understand process. They must put all the pieces together with the right timing and in the right amounts and for the right reasons. 

Innovators are generally not the ones that can take their ideas into action effectively. The experimentation of the ACA innovators crossed an important line - ethical and practical. They skipped the proper steps to small scale testing and went straight to implementation. Their ideas were more important that the impacts. This is the best way to have consequences without benefits.
Health care needs engineering thought and planning. Failure to understand the process, failure in planning, and poor implementation will not only result in failed reforms but also will result in regression - as seen in the last reform attempts. Failures include failure to understand patients, populations, providers, and politics - the state to state political process.

ACA faces the same risk of further restriction or repeal for a number of reasons. It failed to boost primary care before, during, or after implementation. It has caused increasing disruptions from rapid changes and poor implementation. There has been poor provider morale. People have suffered under new taxation and higher costs. ACA and CMS efforts have selected out small practices, small providers, and small hospitals. Insurance companies and others have used the ACA to further their agenda and become even more resistant to regulation and reigned in costs.  More insurance access without sufficient workforce only makes frustrations worse.

Access Is Workforce Empowered, Not Insurance Expanded

Until the experts understand that access is about paid support for the active team members (delivery workforce) to deliver access so that basic services can be delivered, assumptions of insurance coverage as access will continue and will distract from necessary change.

Too little paid for basic office codes for decades is why deficits of access exist and why reforms will fail. The failures are basic to access with failures in cost control and quality improvement shaped by failures in access.

Those who fail to learn from history repeat the same mistakes.

Access Is Workforce, Not Talking About Care
It is so disheartening to see top foundation leaders and top CMS officials talk about access and do little. It is frustrating to see failure after failure in access - something that could actually get them the cost, quality, and other improvements that they hope to achieve.

"We need to be sure that the delivery system provides enough capacity in primary care, especially in rural and targeted urban areas," said Slavitt (acting administrator for CMS).  

How do leaders and administrators get away with talking big while paying little? 

Which is worse, big talk or untested experimentation upon the American people?


Scientific Research Guides Treatment, But Apparently Not Payment

It took 50 years to reign in human subject research such that there was informed consent, protection of vulnerable populations, beneficent intent, and some level of justice. In the rush to rapid change, lines have been crossed. Cost cutting focus compromised beneficent intent as in other decades of changes. Americans further behind and vulnerable have not fared well.

Bandwagons More Important Than Increasing Primary Care Delivery Capacity/Access

Innovators, promoters, and associations have jumped on the bandwagon of primary care medical home. After years of PCMH, more is understood. This includes the substantial additional cost of $105,000 per physician per year as noted in Annals of FM. The quality changes being implemented require another $40,000 for cost of delivery per physician. Where primary care is most needed, the costs of recruitment and retention incentives continue to accelerate.

A detailed review of Primary Care Medical Home indicated mixed results with regard to cost and quality outcomes. Only interventions with substantial funds invested up front in primary care such as $70,000 per physician per year in Vermont have been consistent in the desired results. Michigan Blue Cross also invested in primary care. The right thing to do all along appears to be to invest more in primary care. This is the route to preserving access despite innovation, integration, outreach, and other higher functions. Cuts in primary care spending, cuts in office code payment, delays in payment, costly software and hardware and maintenance, certifications, consultant, and other increasing costs all take a toll. The impacts are worse with regard to small practices. Small practices are half of family physicians. The small practices are on the front lines where health access is most needed.


Substantial funds invested in primary care has the ability to accomplish increased access, decreased costs, and improved quality. Continued stagnation in payment plus penalties and other cost cutting will make matters worse as in past decades.

So What Are Primary Care Associations Doing?

There are few primary care associations left that are truly focused upon primary care as internal medicine, pediatric, nurse practitioner, and physician assistant proportions in primary care have fallen below a majority active and retained in primary care.

What is AAFP planning to do this year? Instead of fighting for real payment for their members suffering most under the changes, AAFP plans to help educate them about the latest chaotic changes CMS is sending their way.  Taking as stand apparently is the difficult route as AAFP focuses on meetings and materials to facilitate more costly changes. How can family physicians afford to pay for even more costs?

How long can AAFP claim to be helping "payment" while supporting payment that makes matters worse for family physicians? - claiming to help payment while not really helping payment is a bad idea. Yes, more complexity in coding and practice can be taught but will this help the bottom line.

The Real Kerfuffle - How much chaos can family physicians stand?

IOM Panel Calls for Training in Social Determinants

Is the IOM Waking Up?

Declines in Health Care Delivery Despite Increases in Health Spending - If We Keep Accelerating Non-Delivery Costs, We Can Continue to Remain Behind Health Care Demand


Primary care can be recovered and should be recovered.

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