President Obama and Proven Health Reform Ideas

JAMA has granted access to government officials for another publication. This time the author was President Obama. One portion of his publication stuck out. "We engaged with Congress to identify the combination of proven health reform ideas that could pass and have continued to adapt them since."

Ideas should easily be recognized as not proven. 

• During an era where legislators are not willing to invest more dollars, there is a good probability of loser and a smaller probability of winner.  
• With government focused on cost cutting as a top priority since 1983, remaining dollars for meaningful use are more limited.
• With a for-profit health care design, winners are magnified and losers are further left behind.
• With strong lobbying by the largest and most organized corporations and associations, the probability of being a loser increases. 
• As we marginalize the local and the individual, those more organized and largest gain even more. 
• Ideas should be discussed with respect and not dismissed as "partisanship and special interest opposition"  
  
  To the President - Congress and others across the political spectrum have treated you poorly, but with this article you have entered a different area - the area of health care Academics. As such Mr. President, you should be willing to review the critique carefully. It is by failures that we learn and ACA has had many failures.

The Winners Are Obvious, But the Losers Fall Behind

Perhaps the words that do not appear in the President's health reform summary give a clue as to the losers. The words primary care, community, rural, underserved, access, cognitive, integrated, and outreach were not included in his work. These are all words that I value most with regard to basic health access - words that I understand as most important when focusing on health reform. The Obama Administration did no better in these areas and added substantially to higher costs of delivery, declines in productivity, burdensome regulation, and marginalization of those delivering care.

Services as a Measure of Health Reform Impact

The American people may also not experience much improvement, as cognitive, primary care, mental health, and basic services are over 65% of the health care services provided each year. Failure to rearrange payments to support the many at the cost of a few was the decision made (or ignored), and with continued consequences. Reforms did result in more insurance coverage of a sort, but this is a small part of access to care - more than negated when the workforce to delivery access is marginalized.

What President Obama Did Not List as Successful Reforms

Reforms did not address the huge burdens that cripple health care. 

• Insurance cost was not addressed - direct in dollars or indirect in impairment of health care delivery. 
• Government regulation costs were worsened - direct or indirect. 
• Reforms did not stop the health care dollars from streaming to administrative and other non-delivery costs. In fact the "reforms" have massively increased these costs.

Failure to Address Corporate Domination of Health Care - The increasing role of health care organizations, drug corporations, and insurance corporations (and their spinoffs) testify to the lack of reform impact. Software and other digital corporations have been added to the corporate benefactors favored by inclusion in health care.

Failure to Address the Concentrations - Reforms did not stop the concentration of most health care dollars and most health care workforce in 1100 zip codes in 1% of the land area where only 10% of Americans are found - leaving most Americans behind in health services and in the economic impact of health care dollars.

Failure to Address the Maldistributions -  Everywhere there are concentrations of patients with Medicare, Medicaid, and other lowest paying plans, there are gaps in primary care, geriatric care, mental health, and basic services. Federal Cause of Shortage Areas Instead of addressing reforms that could have been accomplished, CMS took on quality metrics despite the inability to assign outcomes to a specific physician or to discern a quality physician from the average.

Cognitive/Office/Basic vs Procedural/Technical/Subspecialized - Reforms did not address the massive costs of subspecialty care or stop the flow of MD, DO, NP, and PA away from family practice and primary care to specialty and subspecialty positions. The creation of new types of workforce has only resulted in more new specialties added across MD DO NP PA with more added to each new specialty. To understand the workforce, one need only follow the money.

Perhaps the most important thing to understand about health care reform since 2010 - is how loosely the term is used. If this is all that can be obtained, how will we ever have reform that matters to most of us.

Recent Posts and References  The MACRA Test - Can You Survive the P4P Discrimination? Selling and Swelling a Bigger HITECH Bubble Time to Burst the HITECH Bubble Six Degrees of Discrimination By Health Care Payment Design President Obama and Proven Health Reform Ideas President Obama Stretches Readmissions Gains - If there is any consolation for President Obama and CMS, it may well be that Readmission Penalties took away some of the "poor quality" result of the Bundling Bungling that preceded it (DRGs). This may be the only evidence for Accountable Care working. Of course Readmissions focus has consequences also. Readmissions Better from ACA or Preexistingly Worse from DRG? More Geriatricians Will Not Solve the Geriatric Care Crisis The Great Folly of Health Care Quality Studies Rallying One Hundred for Health Access Not MACRA The Ultimate Government Health Care Paradox - Government must facilitate better EHRs and better health access, not prevent them. Government Compromise of Trauma Response Domino Decline By Design - as ERs Close, Those Nearby Face Challenges, as Small or Rural Hospitals Close or Practices Where Needed... Prevent MACRA to Do No Harm Poor Payment Dictates Poor Training Outcomes in Primary Care No Positive Spin for the Innovator Tailspin - more claims for innovation successes are apparently attempts to hide failure Stop the Promotion To Restore Mental Health Access - claims of mental health care reforms or improvements are a stark contrast from the reality of lowest payment, highest complexity of care, unreliable payment, and poor support other than lots of rhetoric The Consequences of Innovation Procrastination - Distractions due to innovations result in harm to millions who need care delivery, but we have more rearrangements, confusion, reorganization, rapid change, and worse. It is time to stop exhausting possibilities and support those who do the work of front line health access. The Federal Cause of Shortage Areas and Access Barriers - The Federal Design for payment shapes the breadth, depth, and locations of shortage areas due to lowest payments for Medicaid and Medicare and other plan designs that pay least  Primary care can be recovered and should be recovered,  but cannot be recovered when moving the wrong directions Robert C. Bowman, M.D.        Robert.Bowman@DignityHealth.org The blogs represent the opinion of the blogger alone. Basic Health Access Web   Basic Health Access Blog   World of Rural Medical Education