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Health Care Reform's Real Mandate

Renee Despres
Thursday, March 14, 2013 - 22:19

On Thursday, June 28, the Supreme Court of the United States (SCOTUS) upheld the Patient Protection and Affordable Care Act (ACA) of 2010 – popularly known as “health care reform.” The court upheld the law with a vote of 5 to 4, with four liberal justices and conservative Chief Justice John Roberts voting to uphold almost all aspects of the law.

The justices upheld the law’s requirement that all Americans purchase health insurance coverage or pay a fine (the controversial “individual mandate”) but rejected one cornerstone piece of the ACA: a stipulation that the federal government can withdraw Medicaid funding from states that refuse to participate in the expansion of Medicaid called for under the law.

Politicians and media pundits immediately responded to the SCOTUS decision, with opponents and supporters split along party lines. Republican presidential candidate Mitt Romney promised that, if elected, he’d repeal the law his first day in office. President Barak Obama hailed the decision as "a victory for people all over the country whose lives will be more secure because of this law and the Supreme Court decision to uphold it." Other Democrats, such as Nancy Pelosi, hailed the decision as fair and impartial and highlighted benefits the law will bring to families and individuals. Progressive groups including Move-On.org celebrated the outcome but argued that the ACA doesn’t go far enough and that a single-payor system is still the only way to universal health-care coverage for all Americans.

Most of the bickering has centered on the dramatic expansion of health-care coverage called for by the ACA and who's going to pay for it. In all their attention to the Supreme Court ruling on the ACA, few commentators have mentioned the ACA's potential to rebuild and integrate primary care and public health systems in the United States. Implemented well (which, despite the SCOTUS decision, remains a question in this hotly divided political environment), the ACA can help the United States build an effective, integrated public health infrastructure and primary care system to serve its residents.

But the ACA also emphasizes prevention and responsibility, approaching the problem of health care coverage from a population health perspective. Population health focuses on improving the health status of entire populations -- and subgroups within those population. And within that framework lies a second mandate: Individuals, organizations, and local and state governments must become active participants in their own health and the health of their communities. Health is a shared community responsibility.

Health Care Coverage and the ACA

Increasing health-care coverage is a cornerstone of the ACA, and it makes good economic sense. More than 55 million Americans do not have health insurance. Most of them work. Yet two-thirds of bankruptcies in the United States are due to crushing health-care costs for individuals. The benefits of universal health-care coverage also need to be understood in the context of other, non-medical factors – for instance, the cost of lost productivity because of disabling illness or injury, not only for the disabled person but for caregivers and their families.

The ACA spells out the mechanisms by which almost 33 million currently uninsured Americans can become covered by a health-care plan. Starting in 2014, everyone will be required to purchase insurance, with tax credits for anyone making less than 400 percent of the federal poverty level (currently about $15,000 per year for an individual and $30,000 for a family of four).

About 12 million people are expected to enroll in new Insurance Exchanges designed to provide affordable coverage. An additional 6 million young adults fall under one of the more popular provisions of the law: Parents can keep kids on their own health plan until those youngsters reach age 26.

About 17 million people are expected to qualify for free coverage under expanded rules for Medicaid, which expands coverage to adults making 133% or less of federal poverty level. However, this number may shift dramatically, since the court said the federal government cannot withhold Medicaid funding for states that choose not to expand Medicaid to low-income adults. Elected officials and Medicaid directors in several Republican-leaning states -- Mississippi, Florida, and Texas among them -- immediately said they would not expand Medicaid to cover low-income adults, now that the SCOTUS had decided it was optional. In contrast, Democratic-leaning states such as California made it clear that they welcomed the federal assistance to expand health coverage for their residents.

The ACA offers many other health-care benefits to consumers. For instance, insurers can no longer deny someone coverage because of a preexisting condition. This is in effect for children now, and for adults by 2014.  In addition, no co-pay will be allowed for most standard clinical preventive care, including many cancer screening tests such as mammography and colonoscopy, immunizations, well-baby visits, and prenatal counseling.

The ACA and Primary Care

The net effect of this influx of new patients on the primary care system? Staggering. Many of the newly insured people will not have received regular preventive screenings, routine health care, or any kind of health care for years. Many will have undiagnosed conditions – headaches they’ve just dealt with, pain from bones broken years ago, arthritis, skin conditions, poorly controlled or undiagnosed diabetes, cancers, and more. They will need several visits to primary care providers, sometimes to specialists, to get their health-care needs met.

Health-care coverage is an essential piece of the access to care puzzle. But coverage along does not mean access to high-quality health care, especially in rural or low-income urban areas of the United States.At the same time that the ranks of the insured are about to swell, the United States has a critical shortage of health-care providers, especially primary care providers and pediatricians, nurses, and allied health professionals. Every state in the nation has at least one Health Professional Shortage Area (HPSA), an area designated as having a shortage of primary care, mental health, or dental health providers. In some states, such as New Mexico, every county -- or at least a portion of the county -- is a HPSA designated area. As of July 2, 2012, there were 5,703 primary care HPSAs in the nation, along with 4,382 dental and 3660 mental health HPSAs. Often, HPSAs lack not only a primary care health workforce but the physical infrastructure for patient care.

The ACA addresses weaknesses in the primary care system in multiple ways. It contains financial incentives and other support for medical students, nurse practitioners, physician assistants, nurses, and allied health professionals. It expands the National Health Service Corps, which provides scholarships, loan repayment programs, and paid internships. Public health professionals who pledge employment to the public sector or rural communities may also be eligible for loan forgiveness. It promotes the concept of "coordinated care" -- providers who work together to provide care across the spectrum of a patient's needs, including primary care, specialty care, social needs, and health education.

Is it enough? In the short term, no. There’s no way that by 2014, medical schools, nursing schools, and allied health schools will turn out enough qualified, skilled primary care providers and pediatricians to make up for critical health care provider shortages. It takes more than a years of school and residencies to become an effective, skilled primary care provider. It takes actual “practice” – one must always be a "practicing" provider. It takes seeing patient after patient, learning from each one, gaining experience in an environment where other skilled providers can offer mentorship and support, and learning from other members of the health-care team.

Yet many experienced primary care providers are approaching retirement age, reducing the pool of mentors. And in rural areas, newly-graduated providers are often assigned to run clinics by themselves, with little support and no mentors close by.

That's the short term. In the long term, the providers trained under the ACA will become that next generation of providers. And the ACA has made primary care more attractive -- not only by sweetening the pot for medical students and midlevel providers, but by increasing Medicaid payments to primary care providers in 2014. 

No commentary on the ACA and primary care would be complete without at least a brief mention of the most effective primary care delivery system in the U.S.: community health centers (CHCs). Community health centers form the backbone of health care in rural and underserved communities, providing primary care, dental, and mental health services on a sliding fee basis. The ACA provides significant funding to CHCs for staffing, developing physical infrastructure,, electronic recordskeeping, and more.

An Emphasis on Prevention

It’s cheaper to prevent disease and injury than it is to treat disease and injury. Which would you rather pay for – a flu shot, or a visit to the doctor and two weeks off work while you and the rest of your family pass it around? Someone to help you quit smoking, or chemotherapy for lung cancer? New grip bars in Grandma’s shower, or an ambulance ride and emergency room visit when she falls and fractures her hip?

The ACA requires health plans to fully cover preventive screenings and wellness visits for children. That's the clinical preventive medicine side. On the public health side, prevention and health promotion are critical components of the ACA, which funded development of the first ever national prevention and health promotion strategy for the United States. The comprehensive and clearly articulated plan, which was published in June 2011, provides a framework for injury and disease prevention and reducing health disparities.

That's a fundamental shift for any piece of legislation regarding the U.S. health-care system, which has been built largely on reactive, not proactive, medicine. As the writers of the strategy note, "The National Prevention Strategy will move us from a system of sick care to one based on wellness and prevention. It builds upon the state-of-the-art clinical services we have in this country and the remarkable progress that has been made toward understanding how to improve the health of individuals, families, and communities through prevention."

Need to Know: Understanding Prevention

When prevention specialists talk about preventing disease, they generally divide prevention efforts into three categories: 

  • Primary prevention means preventing disease in the first place. Immunizations, teaching kids healthy eating habits, maintaining a healthy weight, not smoking in the first place.
  • Secondary prevention means preventing disease if you’re at risk. Overweight? Losing a few pounds will reduce your risk of heart disease, stroke, diabetes, and orthopedic injuries. Secondary prevention might also target people at high risk of particular diseases -- for instance, family members of people with diabetes.
  • Tertiary prevention means preventing acute episodes of chronic disease – and in most cases, slowing disease progression. For a person with heart disease, it might mean helping to manage medications; for a person with diabetes, nutritional counseling and joining an exercise group.
Nice to Know: How to Spend Less on Health Care

According to Ezekiel J. Emanuel, MD, PhD: in “Where are the Health-Care Cost Savings?” some of the biggest health-care cost savings could be realized by providing better tertiary preventive care for people with existing chronic diseases.

Of course, the savings would probably be much greater were those people never to develop those diseases in the first place, which means putting in place effective primary or secondary prevention programs. But the reality is that, in the 21st century, most of us will live long enough to develop some sort of chronic disease -- and we'll need to learn how to manage it to keep ourselves out of ambulances and hospital emergency rooms.

Emanuel cites estimates that suggest “as much as 22% of all health-care expenditures is related to potentially avoidable complications such as hospital admissions for patients with diabetes with ketoacidosis or amputation of gangrenous limbs or of patients with congestive heart failure for shortness of breath due to fluid overload. Thus, reducing avoidable complications by 10% could save more than $40 billion per year.”

Ultimately, Emanual argues, “reducing unnecessary medical care for chronically ill patients is about improving tertiary prevention.” He cites four specific strategies that have been successful: (1) installing electronic health records and using them to track patients' health status and physician performance, as well as using decision supports to increase adherence to treatment pathways; (2) using the information for more intensive interactions between patients, caregivers, and clinic staff, including use of care coordinators, 24/7 access, interventions to increase medication adherence, specialized clinic services for recurrent problems of patients with chronic disease such as anticoagulation clinics; (3) reducing use of specialists, and when specialists are involved using those who are more efficient; and (4) providing services not traditionally covered by fee-for-service reimbursement, such as e-mail, wireless monitoring to increase medication adherence, home evaluations to minimize falls, lifestyle interventions to improve nutrition and exercise, and transportation services for office visits.”

All four of these strategies are fundamental to the ACA. When these strategies are implemented, the chronically ill are hospitalized less frequently, make fewer emergency department visits, and use less specialist services – all of which add up to less expensive health care.

The "Public" in Public Health

Yet preventing injury and disease, as easy as it seems, requires individuals to change their health behaviors – and those changes can be either supported or thwarted by the communities in which they live. The ACA links the clinic and the community by calling for an integration of primary care and its even poorer cousin, public health.

That’s the other dirty little secret about health in the United States: The U.S. public health infrastructure is “seriously and systematically underfunded” (Baker, et al.), leading to huge gaps in the system – and threats to everyone's health. For instance, public health surveillance systems are often 2 to 3 years behind actual data. And most people working in public health -- especially in government agencies -- have little to no training in public health.

Although the Public Health Improvement Act of 2000 began to address some of the gaps in public health systems, public health generally remains a low priority for local, state, and federal government.

Unfortunately, public health in the United States is commonly thought of only in its clinical aspects. After all, isn’t the public health clinic where low-income folks go when they need immunizations or HIV testing or condoms?

But clinical public health is only a tiny fraction of the field. Some health promotion interventions are individual: immunizations, teaching about nutrition, how to quit smoking. Others are society-wide: clean water, air quality, reducing pesticide exposure, smoking bans. Even health promotion is a small portion. Surveillance, workforce development, infrastructure development -- all fall under public health's auspices.

Partly as a result of subpar funding of public health, the United States is plagued with fundamental inequalities in health status, called health disparities. Health status breaks down sharply along ethnic and socioeconomic lines. Happen to be African-American? You’re significantly more likely to develop high blood pressure, heart disease, diabetes, and a host of other chronic diseases. Happen to be a young man of color? According to a 2009 Rand Corporation Report cited by the California Endowment Outcome Resource Guide on men and boys of color, you’re more than six times as likely to have someone near to you murdered as is a white youth. If you're a young Black man, you're 16 times more likely than your white peers to be murdered yourself.

One important measure of the a nation's health is its infant mortality rate -- that is, how many infants die during childbirth or within the ensuing month. Infant mortality rates serve as indicators of other aspect of health, including socioeconomic status, access to health care, and maternal health. According to the Centers for Disease Control and Prevention (CDC), the U.S. infant mortality rate was 6.62 per 1000 live births in 2008. That places the United States 41st –  slightly worse than Croatia -- in infant mortality.

Break that the rate into ethnic groups, and the disparities become embarrassing. In 2007, the infant mortality rate for non-Hispanic blacks was 12.67 per 1000 births in 2008, compared to 4.51 for Asian or Pacific Islanders. The rate for Non-Hispanic whites was 5.52. Put another way, a non-Hispanic black infant is about as likely to die during childbirth as is an infant in Dominica or Aruba.

The rate also varies by state. In Mississippi, it's 10.16. In our nation's capital, Washington D.C.,11.97 out of 1000 infants die at birth. The most stunning: the infant mortality rate for non-Hispanic Black women for 2006-2008 in Hawaii is 18.54 -- about the same as Armenia.

These disparities, for the most part, have very little to do with genetics or individual responsibility – and everything to do with environment, access to health care, and health literacy. Yet known and effective public health interventions have not reached many communities in the United States.

Take a look at the billboards in any low-income urban area. Count the signs that advertise booze, cigarettes, and fast food. Count the fast food restaurants, corner stores, and liquor stores. Then count the full-service grocery stores. How many places can you walk into and see a display of fresh fruits and vegetables, water misting over them to keep them fresh, produce workers busily stocking the refrigerator shelves? Oh. Zero? Thought so. Look at the parks. Would you want your kids to play there? Would you (or do you, if you live there) feel safe walking for exercise? Sending your kids to school on their bikes?

The Real Mandate

Opponents to the ACA often respond to these arguments with the deflating question: "And who's going to pay for all this?" Prevention programs may be cost-effective, but they are not free or even cheap. And building a primary care and public health infrastructure is going to cost money.

But we are paying far too much right now. We're paying not only in dollars, but in lost productivity, lost years, unnecessary pain and suffering. The costs of not doing anything are even greater. We face rising obesity rates, an aging population with complex health-care and social needs, and less and less employer-sponsored health-care coverage. The old model is not working. 

The ACA responds to these challenges with a complex but informed strategy. Ultimately, it contains a second "mandate." But this mandate cannot be legislated, argued in a court of law, or repealed. It's simply a truth of the complex ecology of health and community. To repeat myself: Individuals, organizations, communities, local and state governments must become active participants in their own health and the health of their communities.

Perhaps one reason why ACA opponents are so vociferous is that this legislation points out this  "elephant in the room" -- and calls for each person to step up and take responsibility not only for his or her own health, but for the health of our communities. I find it intriguing that so many of the law's fiercest opponents are also devout Christians. What happened to "love thy brother as thyself" and all those truisms?

Here's what health care reform asks of us:

  • Individuals: For individuals, that ecological health mandate means adopting healthful habits. Eat less sugar, fat, and salt; eat more fruits, vegetables, and unprocessed foods. Stay away from fast food, sodas, and other empty calories. Exercise at least 30 minutes a day. Get recommended screening at the recommended ages. Know your family and personal health history.
  • Employers: For employers, the ecological health mandate means maintaining a healthful work environment -- and supporting workers' efforts to improve their own physical and mental health. Bring bagels and water, not donuts and soft drinks. Provide incentives to exercise and learn about healthy habits. Participate in evidence-based workplace wellness programs.
  • Local governments: Develop policies that support community and individual health. Create and enforce smoking bans. Invest in parks, recreational facilities, bicycling trails, walkways, and innovative physical designs that encourage people to get out of their cars. Support employers' efforts to maintain a healthy workforce. Find out which community residents are "falling through the cracks" of health care, and support them.
  • States: Identify and prioritize health needs of all communities and populations. Provide a fair and equitable system for addressing those needs, including primary care, mental, and oral health needs, emergency care, and specialist care. Understand that healthy populations are economically and socially viable populations.

With the ACA, President Obama, Congressional Democrats, and now the SCOTUS have given us the opportunity to re-vision the economics, morality, and ethics of health care in the United States. Will we step up to the challenge? It will take courage, ingenuity, and compassion to truly "re-form" our public health and primary care systems. We must acknowledge that our health and our futures are wound together in an intricate network of individual, community, and government responsibility.



Emanual, E.J. (2012). "Where are the Health Care Cost Savings?" (2012).  JAMA. 307(1):39-40. doi:10.1001/jama.2011.1927

Mathews, T.J., MacDorman, M.S., Macorman, M.F. (2010). "Infant Mortality Statistics from the 2008 Period Linked Birth/Infant Death Data Set." Centers for Disease Control and Prevention, Division of Vital Statistics. National Vital Statistics Reports. 60:5. http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_05.pdf

McMahon, L.F., Chopra, V. "Health Care Cost and ValueThe Way Forward." (2012). JAMA. 2012;307(7):671-672. doi:10.1001/jama.2012.136 http://jama.jamanetwork.com/article.aspx?articleid=1104992


Additional Resources:

Healthcare.gov: www.healthcare.gov

Kaiser Family Foundation Health Care Reform Source http://healthreform.kff.org/