More than three years deep into the Affordable Care Act, 13 months since the U.S. Supreme Court confirmed its constitutionality, and almost 10 months after the American public approved reform through the Electoral College, modern American health care is now poised to shine or make its claim as a historical disaster. As the nation prepares for the health insurance exchange, the next few months shall prove critical in determining the trajectory — and thus the fate — of our health care system, and we would be remiss not to notice the storm clouds forming overhead.
Despite the progress fueled by its recent success, the Affordable Care Act now finds itself in a holding pattern that to some eyes suggests turmoil in the months to come. As things now stand, at least one mandate has been delayed, Medicaid expansion has yet to blossom as fully as predicted, and Pioneer accountable care organizations, or ACOs, have begun to unravel. Furthermore, the proposed reductions in Medicare disproportionate share payments are slated to commence on Oct. 1, the same day the next phase of the hospital value based purchasing program takes effect. Although the upcoming set of Medicare Shared Savings Program ACO selections may generate some reform-related momentum, something as trivial as a few poorly timed, misfired state exchanges could be enough for an injunction stopping them all in the name of equal protection. These seemingly contradictory elements force those in the industry to ask the question: Is modern American health care truly at a strange new crossroads, or have we as a nation traveled this path before?
The uncertainties that accompany any historical reform such as the Affordable Care Act are of course to be expected, and our health care history is riddled with similar examples. Forty-two years ago the “debate on health care in the United States [was] of the first order of importance to the health professions, and of no less importance to the political future of the nation, for precedents [set then would] be applied to the rest of American society in the future.” See Richard M. Sade, M.D., “Medical Care As a Right: A Refutation,” 285 (No. 23) N. Engl. J. Med. 1288 (Dec. 2, 1971).
The same can be seen when comparing industry reactions to some of health care’s more prominent evolutionary markers. Historically speaking, certain structurally changing concepts such as ACOs and the patient centered medical home are not as dynamic as it would initially appear when viewed in the big picture. “A new concept of practice requires a new type of facility to replace, or perhaps to supplement, the hospital, which has become the center of health care but is now inadequate. The new concept of the community health center is needed. This should be combined with hospital-based group practice, which is undoubtedly the best way to bring health services to the people.” Russel V. Lee, M.D., “Provision of Health Services,” 277 (No. 13) N. Engl. J. Med. 682 (Sept. 28, 1967).
In this context, the present state of physicians should come as no surprise. Just as doctors abandoned the hospital setting almost 50 years ago in favor of Part B, today’s physicians now find themselves exiting the Medicaid program en masse as they take aim at Medicare while battling this most recent round of imperialist hospital spending sprees. Caught in the resultant cross-fire, patient perception of the physician plummeted around the same time that Gregory House replaced Marcus Welby as the quintessential physician in American pop culture.
Structural uncertainties aside, there is comfort in knowing that the stakes remain largely unchanged since the introduction of Medicare. “The implementation of a law so extensive and complicated as Medicare will involve the private physician in a bureaucratic pattern perhaps more complex and frustrating than he has ever seen. The paperwork he now complains about will be inconsequential by comparison. Such is the nature of a bureaucracy, especially one implementing a program costing billions of dollars and affecting millions of people.” “Medicare and the Physician’s Responsibility,” 273 N. Engl. J. Med. 447 (Aug. 19, 1965).
In times of flux, historical lessons often provide meaningful insight and offer much-needed clarity by showing a prior resolution in the form of its individual steps. The billions of dollars designated to flow into today’s health care system will help to build a greater infrastructure, to be sure, while hospitals and insurance companies shall certainly benefit in this recent era of reform. The greatest value to be found in the influence of the Affordable Care Act, however, lies in the achievement of that all-important third step, when factors old and new combine to rebuild that ever-tenuous bridge between doctors and their patients.