One year ago today, we were not talking about same sex marriage or voting rights. The topic du jour was the U.S. Supreme Court's (SCOTUS) dramatic and surprising ruling on the constitutionality of the Affordable Care Act/Obamacare.

Were it not for a late change of mind/heart by Chief Justice John Roberts, the entire law would have been overturned. Instead of throwing out the ACA or the individual mandate, the only significant change was the "Roberts' Rule" that made the ACA's mandatory Medicaid expansion an option for states.

When the ACA's history is written, June 28 2012 will be recognized as one of a handful of the most fateful days in the history of this most-important round of U.S. health reform. It's up there with:

12/24/2009: the day the U.S. Senate approved its version of health reform

1/19/2010: the day Scott Brown won the Massachusetts U.S. Senate seat, denying Senate Democrats their crucial 60-seat majority

3/23/2010: the day President Obama signed the Patient Protection & Affordable Care Act into law

11/6/2012: the day President Obama was re-elected, removing the last potential fatal threat to full implementation of the ACA

How different U.S. health policy would be today had Chief Justice Roberts not abandoned his four conservative colleagues. And what a compelling and surprising 12 months it has been since the SCOTUS decision was handed down. Let's recall ten major ACA-related trends, events, and developments of the past year (links from the always excellent Wonkblog at the Washington Post):

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So many articles and exposes have appeared over the past year since Stephen Brill's powerful Time Magazine "Bitter Pill" tome on the pricing disparities everywhere in  U.S. medical care. The weakness of Brill's article was its idea deficit on what to do about it. Government price setting is one answer, widely used in most other nations, and politically impossible in the U.S.  Is there anything else other than huge point-of-service cost sharing by consumers in the form of co-payments, coinsurance, and deductibles?

Something else, called "reference pricing," is starting to take off, and it may just be the medicine that our broken medical care pricing system needs. Check out today's New York Times article to learn more about it.

What is "reference pricing?"

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I always thought one of the shames of the 1993-94 failure of Clinton health reform was the missed opportunity to implement reform during a period of economic recovery when more solid public budgets and rising living standards would have made implementation much easier. I also recall passage of an ambitious Massachusetts health reform law back in 1988, just before the state's (and nation's) economy went into the dumps -- gutting the law was easy in an economic crisis.

By this logic, the implementation of the Affordable Care Act (ACA, Obamacare) now, during this period, is fortuitous. There is no better time to implement such a law than during a period of economic recovery. And even better, there is increasing evidence that Obamacare is helping -- not harming -- that economic recovery.

Further evidence came yesterday with two new reports suggesting that the slowdown in the rate of U.S. health spending growth is more than a reaction to bad economic times, and can be seen as a reflection of structural changes wrought by the ACA.

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Back in April 2012, I blogged about a new campaign launched by the American Board of Internal Medicine Foundation to highlight commonly used medical procedures that nine key U.S. physician specialty societies agreed should not be commonly done. Each of the nine societies, representing 374,000 U.S. physicians, came up with five recommendations, 45 in all. Click here for my previous post listing all 45 recommendations.  The campaign is called Choosing Wisely and you can find its site by clicking here.  

I did wonder at the time how effectively this worthy campaign would be promoted.  Since then, sorry to say I have heard nothing about the Choosing Wisely campaign. 

Until today...

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I have been wondering if the drumbeat of public pressure on the cost of U.S. medical care would continue or abate. It's looking like it may just continue for a while.

I hope as many as possible have the chance to read the front page article in this past Sunday's New York Times on the high cost of U.S. medicine, with a particular focus on the development of colonoscopies -- The $2.7 Trillion Medical Bill. While colonoscopies account for only about $10 billion of our $2.7 trillion health spending, there's a tale to be told, and rarely has it been told so well.

Some of the highlights that struck me:

No surprise, prices for the procedure vary all over the map from a low of under $2,000 to a high as much as nearly $20,000. The only consistency is that the price of a colonoscopy everywhere in the U.S. is much higher than the price in any other industrialized nation. American exceptionalism, for sure. And not just for colonoscopies, but for any medical procedure you can name. "The U.S. just pays providers of health care much more for everything," said health expert Tom Sackville.

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A story in today's New York Times, "Partisan Gridlock Thwarts Efforts to Alter Health Law," deserves attention and I hope it gets some.

Just about every major law I have studied has been subject to repeated amendment and alteration after its passage, both federal and state. When I served in the Massachusetts legislature, "technical correction bills" were as normal as spring showers following passage of any major new law. It is the normal state of affairs with complex legislation. Once a complex new statute nears implementation, an array of issues, surprising or not, come to the fore in need of change or clarification. Usually, 99.9+% of the public has zero awareness that this goes on routinely, in ways big, small and hard to discern. It is the normal business of a legislative assembly. But the politically charged environment around the ACA has made that normal process inconceivable.

Still, even the Affordable Care Act has been subject to at least seven significant legislative modifications (not counting last summer's Supreme Court change relating to Medicaid) since its enactment in March of 2010.

Just like any other complex statute, there is a lot in the ACA that could use modification or clarification, felt by folks on both sides of the partisan divide. Some changes would be 100% unacceptable to Republicans, and many would be absolutely toxic to Democrats. And, many value-added changes would be potentially OK to both sides. Except, as the Times story makes clear:

 "... as they prowl Capitol Hill, business lobbyists like Mr. DeFife, health care providers and others seeking changes are finding, to their dismay, that in a polarized Congress, accomplishing them has become all but impossible. Republicans simply want to see the entire law go away and will not take part in adjusting it. Democrats are petrified of reopening a politically charged law that threatens to derail careers as the Republicans once again seize on it before an election year. As a result, a landmark law that almost everyone agrees has flaws is likely to take effect unchanged."

I don't think the process to find politically acceptable modifications to the ACA can start on Capitol Hill. This process needs to start, though not there. It needs to start in the world of the think tanks and policy groups where experts operate with more degrees of freedom than  permissible on Capitol Hill. The effort may not even bear fruit for some time to come, maybe not even for several years.

Last week, I had breakfast with Prof. Larry Susskind of MIT and Harvard Law, and the director of the Consensus Building Institute that attempts mediation in some of the hottest and bleakest disputes on the planet. "When things are most bleak," he said to me, "that is precisely the time to sit down and attempt to negotiate."

Why not?

For most of this year, we've heard a steady drumbeat of pessimism that the costs of health insurance policies under the new plans to be managed by state-based Exchanges or Marketplaces will be unaffordable, dooming the success of the Affordable Care Act. In the past two weeks, though, we seen evidence from Oregon, Maryland, and now California that premiums will be far below the doom-and-gloom levels predicted by the pessimists.

As the Washington Post's Sarah Kliff explains, in California:

"Health insurers will charge 25-year-olds between $142 and $190 per month for a bare-bones health plan in Los Angeles. A 40-year-old in San Francisco who wants a top-of-the-line plan would receive a bill between $451 and $525. Downgrade to a less robust option, and premiums fall as low as $221."

And those levels are for purchasers with household income over 400 percent of the federal poverty level ($44,680 for a single adult). The vast majority of applicants will be in households with incomes below that, and thus eligible for premium subsidies and cost-sharing protections.

This did not happen by accident.

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Check out a great new resource on the Massachusetts health care system from the Blue Cross Blue Shield Foundation of Massachusetts: the Massachusetts Health Care Delivery System Map. As the state's new Health Policy Commission seeks to get its mind and arms around the issue of market concentration, the Foundation's new site boils the issue down to the key factors in an impressively accessible and compelling way.

For example, if you want to begin to understand why Partners Healthcare is so dominant in the state's healthcare market, don't go to this page, Hospital Systems by Size, on which Partners is #2 after Steward Health Care System.  Go this this page: Physician Networks and Major Medical Groups, where the size of Partners' physician network (called Partners Community Healthcare Inc., PCHI, or "peachy") is larger than #2 (Steward) or #3 (Atrius), combined. 

Or look at hospitals by Net Patient Service Revenue, and see that Partners total NPSR in 2010 ($4.2 billion) was the same as #s 2 (UMass Memorial), 3 (Steward), and 4 (Beth Israel Deaconess) combined.

Don't forget this helpful page of Recent Changes in the Massachusetts health care market.    

I found the page on Inpatient Capacity helpful as well.  Yes, Partners dominates the Boston market, but no other, not even in the Greater Boston market.  Pretty much every region (except for Northeast Mass.) has a single dominant player.  The biggest is UMass Memorial which owns 54% of the inpatient capacity in Central Mass.  If anything, this page helps to understand why inpatient hospital capacity is no longer the essential feature of market dominance that it used to be.  It's about the docs.

So much more to explore in this highly useful and accessible tool as the state debate over cost and market dominance continues.  Kudos to Massachusetts Health Quality Partners which did the legwork on this terrific resource.

And congratulations to the Foundation on choosing a new Executive Director to succeed Sarah Iselin.  Their choice is Audrey Shelto who has been a highly respected professional in government and non-profit health care in Massachusetts for three decades.  An excellent choice to ensure that the Foundation continues its useful and important work for the Massachusetts health system.

Is Medicaid worth it? More specifically, is being on Medicaid better than being uninsured?

This past week, we witnessed a surprising and heated argument over these questions. On Thursday, the New England Journal of Medicine published "The Oregon Experiment -- Effects of Medicaid on Clinical Outcomes." The results are already being used by folks trying to influence state decisions on whether or not to expand Medicaid eligibility as authorized under the Affordable Care Act.

In short, it's a study with impact. First, let's back up.

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Today, President Obama addressed the controversies over implementation of the Affordable Care Act. You can read his complete remarks here, and here is his summation:

"And -- and the last point I'll make, even if we do everything perfectly, there'll still be, you know, glitches and bumps, and there'll be stories that can be written that says, oh, look, this thing's, you know, not working the way it's supposed to, and this happened and that happened. And that's pretty much true of every government program that's ever been set up.

"But if we stay with it and we understand what our long-term objective is, which is making sure that in a country as wealthy as ours, nobody should go bankrupt if they get sick and that we would rather have people getting regular checkups than going to the emergency room because they don't have health care -- if -- if we keep that in mind, then we're going to be able to drive down costs, we're going to be able to improve efficiencies in the system, we're going to be able to see people benefit from better health care, and that will save the country money as a whole over the long term."

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Two articles this past week, each written in whole or part by Harvard's Atul Gawande, put our health care and hospital dilemma into exquisite perspective.

First, one can only feel admiration and respect for the incredible job done by Greater Boston hospitals and hospital personnel in the wake of the Marathon bombing. Our hospital system, our physicians and nurses and emergency personnel from across the City and beyond rose to the challenge in a deeply impressive way. If there was ever a moment to take collective pride in the world's most concentrated academic teaching hospital environment, this was it.

Here's a good account from USA Today highlighting the extraordinary efforts of our local and regional medical system in the wake of the terror.

As usual, Atul Gawande, the prize winning author, surgeon, and Harvard faculty member, put a special spin on it in a brief report for The New Yorker explaining Why Boston Hospitals Were Ready:

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A new report on state-by-state trends in employer-sponsored health insurance (ESI) caught my eye both for the national and Massachusetts trends, comparing 1999/2000 with 2010/2011. Bottom line from the Robert Wood Johnson Foundation-funded State Health Access Data Assistance Center: big changes nationally and in most states, and not so in Massachusetts. Some key findings:

The percent of non-elderly who obtain health insurance from their employers declined from 69.7 to 59.5 percent over the decade, a stunning 10.2% drop -- public coverage increased by 3.1% in the same period.

The share of private firms offering health insurance dropped from 58.9 to 52.4%, and the "take up rate" (the percent of workers accepting employer offers) fell from 81.8 to 76.3%.

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Here's an info-graphic designed by a team from the George Washington University School of Public Health as part of National Public Health Week (last week). It's pretty smart and worth a look:

OK, you probably haven't noticed, but April 1-7 2013 is National Public Health Week.  The American Public Health Association is leading this week's recognition and has created the above-linked spiffy website.  Lots of Schools and some cities and towns are noting and doing something special this week.  Though the Massachusetts Public Health Association seems not to have gotten the memo.  And ditto for my own institution, the Harvard School of Public Health. 

It's always been true that public health is not good at celebrating itself and APHA is to be congratulated for giving it a push.  And it's too bad because public health in the U.S. deserves more attention, resources, and credit than it gets. 

So let's review a little.

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If Maryland health officials have their way, their state's health care financing system is going to resemble key elements of the Massachusetts health care financing system as adopted by our Legislature and Governor Patrick last August. Click here to read Maryland's 136-page proposal to the federal Centers for Medicare & Medicaid Services (CMS). If adopted, Maryland will be the second state, after Massachusetts, to establish a framework to keep health care costs rising no faster than the growth of the state economy.

What's that saying? One is an accident, two is a trend, and three is a movement. But I'm getting ahead of myself.  Let's review some history:

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This weekend marks the third anniversary of the signing of the Patient Protection and Affordable Care Act (PPACA) by President Obama on March 23 2010. One week later, the President signed a companion act, the Healthcare Education and Reconciliation Act of 2010 (HCERA), consisting mostly of changes to the PPACA necessary to secure that Act's passage in the House of Representatives. The combined two laws are collectively referred to as the Affordable Care Act, or ACA, or Obamacare.

It was a wild legislative ride to passage and it's been a wild implementation ride for the three years since then. By my count, the ACA has survived three near-death experiences. The first occurred in utero with the January 19 2010 election of Republican Scott Brown to the US Senate seat from Massachusetts, depriving Democrats of a vital 60-seat majority, and convincing many that health reform was dead; the second was the US Supreme Court decision on June 28 2012 when complete repeal of the entire law was averted by a late change of mind/heart by Chief Justice John Roberts; the third was on November 6 2012 when a Republican victory for White House and Senate control would have led to certain repeal.

While the brushes with death are over, huge challenges remain -- especially leading up to those coming on January 1 2014 when these enormous reforms all take place on the same day:

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I have a new article just made available on the website of the New England Journal of Medicine on budget sequestration and the U.S. health sector, available here. I explain the sequestration process, how key federal health-related functions will be affected, and why this is happening. One quote:

The Food and Drug Administration projects that it will conduct 2100 fewer inspections at domestic and foreign food manufacturers (down from just over 20,000 in 2012). The Substance Abuse and Mental Health Services Administration plans to cut the Mental Health Block Grant program, eliminating services for 373,000 (of about 6.9 million) adults and children and cutting inpatient admissions for addiction by 109,000 (from about 1.8 million). The Indian Health Service, which normally covers about 48,000 inpatient admissions and 12.8 million outpatient visits per year, expects to cover 3000 and 804,000 fewer, respectively. The Health Resources and Services Administration anticipates cuts to AIDS drug-assistance programs, with 7400 fewer patients' receiving HIV medications as a result (about 209,000 received treatment in 2010).

A lot of damage, and none of it needs to happen. 

Oftentimes, it seems to me that tobacco and smoking prevention are yesterday's issues. Been there, done that. Sure, six million persons die every year globally due to smoking and secondhand smoke (about 440,000 in the U.S., according to the Centers for Disease Control & Prevention). Sure, when tobacco is used as intended, about half of smokers will die from causes directly related to its use.

But, so few folks I see still smoke. It must be disappearing.

Or so I thought.

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Way back in 1993, I met Dr. C. Everett Koop MD, the nation's most recognized and respected Surgeon General (he served in the 1980s under President Reagan). We met at an event at the Federal Reserve Bank in Boston where he and I both received awards from Health Care for All.

Reading about me in the event program, he noticed that I was the product of a Jesuit education (B.C. High and Boston College). With that knowledge, he felt safe tossing me a phrase in Latin: "Illegitimi non carborundum." I didn't have the nerve to tell him I didn't have a clue what the phrase meant, so I just shook his hand and said: "Thank you, sir!"

In 1993 there was no Web to find out translations instantly, so it took a little time for me to find out what it meant. I finally did: "Don't let the bastards grind you down."

I thought of that encounter last week at the sad moment of learning of Dr. Koop's passing. But I had also thought of it a few days before when I read a New York Times column by Mark Bittman raking our current Surgeon General, Dr. Regina Benjamin, over the coals for her near-invisible public profile and other sins:

"No one I asked (including a member of Congress) could name the current one. She’s Regina Benjamin — and no, I didn’t know, either. In theory, the surgeon general is the nation’s doctor, an independent practitioner whose major concern is our health. In reality, the position has been eviscerated..."

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Way before the fight over creating the Affordable Care Act, broad agreement existed on one vital national health reform issue: the nation's health care workforce shortages. Even without the ACA, America faced serious problems with deficits of physicians, dentists, pharmacists, mental health professionals, and many more. With passage of the ACA, these issues assumed more urgency because of the pending expansion of health insurance to 30+ million formerly uninsured Americans.

The ACA sought to address these needs. Title V of the law is devoted entirely to measures to address America's health care workforce needs. No other title of the law received such broad support and so little controversy as did Title V.  During the legislative debate on the ACA, I heard condemnation of nearly every part -- except for Title V.  Here's the description of the Title from healthcare.gov:

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The widely shared wisdom about Medicare and Medicaid is that the programs are in crisis because of rapid and uncontrollable spending increases. Many say the only solutions are to raise the Medicare eligibility age to 67 from 65, block grant and cut Medicaid payments to states, and undertake other draconian steps to reduce eligibility, benefits, and cost protections from the programs' 112+ million enrollees.

The conventional wisdom is wrong, and the evidence keeps getting stronger. See this chart below from a new report by the Center on Budget and Policy Priorities:

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The period since the November 6th federal elections has been a remarkably fluid period in U.S. politics and policy -- more than anyone could have anticipated.  The Republican Party embraced tax increases for the wealthiest Americans to avoid the "fiscal cliff;" prospects for federal immigration reform legislation have changed from impossible to more than likely; gun control, an issue on which Democrats have feared to tread since Al Gore's loss in the 2000 presidential election, has re-emerged with gusto since the Connecticut school shootings. 

And change is affecting prospects for the Affordable Care Act/ObamaCare as well.  In the past two days, we have seen developments inconceivable before November 6th.

First, yesterday, Florida Governor Rick Scott became the 7th Republican chief executive to endorse the ACA's Medicaid expansion for his state.  More than Arizona's Jan Brewer and Ohio's John Kasich, Scott has been the most virulent opponent of the ACA before nearly anyone else.  Back in 2008, even before Obama took the oath of office, Scott was using part of his large fortune to finance TV ads opposing health reform.  Though Scott repeatedly denounced the ACA's Medicaid expansion, yesterday he said:

"While the federal government is committed to pay 100 percent of the cost, I cannot, in good conscience, deny Floridians the needed access to health care."

Scott only endorsed the expansion through 2016, the first three years when the federal government pays 100% of the cost.  After that, the federal share gradually declines over three years to 90%.  And there is no guarantee that the Republican controlled Senate and House will go along with Scott's recommendation.  Scott is already facing a vigorous 2014 re-election challenge from former Republican Governor Charlie Crist (who turned Democrat last year).  This recognition of reality by one of the nation's fiercest ObamaCare critics is an important political signals of the changing landscape for the ACA.

Second, yesterday Douglas Holtz-Eakin, president of the American Action Forum, who served as director of the Congressional Budget Office from 2003 to 2005 and Avik Roy, a senior fellow at the Manhattan Institute, and a 2012 healthcare adviser to Republican nominee Mitt Romney, published a Reuters column calling on conservatives to now focus on modifying rather than repealing the ACA:

"For far too long, conservatives have failed to coalesce around a long-term vision of what a free-market healthcare system should look like. Republican attention to healthcare, in turn, has only arisen sporadically, in response to Democratic initiatives.

"Obamacare is the logical byproduct of this conservative policy neglect. President Barack Obama’s re-election was a strategic victory for his signature healthcare law. Once the bulk of the program begins to be implemented in 2014 — especially its trillions of dollars in new health-insurance subsidies — it will become politically impossible to repeal. And as the baby boomers retire and Obamacare is fully operational, government health spending will reach unsustainable levels.

"The great irony of Obama’s triumph, however, is that it can pave the way for Republicans to adopt a comprehensive, market-oriented healthcare agenda.  The market-oriented prescription drug program in Medicare has controlled the growth of government health spending. Similarly, conservatives can use Obamacare’s important concession to the private sector — its establishment of subsidized insurance marketplaces — as a vehicle for broader entitlement reforms."

In other words, rather than a socialist takeover the U.S. health care system, the ACA is actually a concession to a private market vision of how the system can reflect conservative principles.  This from one of the nation's leading conservative policy critics of ObamaCare for the past three years. 

From me, no gloating, no "I told you so," no smugness.  Instead, I feel appreciation for common sense overtaking extremism and myopia.  Thanks to Gov. Rick Scott, Douglas Holtz-Eakin, Avik Roy, and others, we are reaching the point where Congress can consider how to improve and enhance the ACA.

Better times ahead, just in time.

This past week, I had the opportunity to interview Dr. Donald Berwick at a Harvard School of Public Health forum. We talked about his early days in the 1980s when he started the now-world famous Institute for Healthcare Improvement, based in Cambridge. We discussed his movement in the 1990s into health policy that led to the ground-breaking Institute of Medicine reports: To Err Is Human and Crossing the Quality Chasm. He reflected on his 17 months running the U.S. Centers for Medicare & Medicaid Services (CMS). And he looked ahead to his nascent campaign for Governor of Massachusetts in 2014.

Regular Health Stew readers already know I am a huge fan -- see this post from when he left CMS, Why Berwick Matters.

If you would like to see the full interview, click here. It runs 55 minutes and includes questions from HSPH students. Here's a link to a Harvard Gazette story on the interview. 

On a lighter note, I had the chance to ask him what it is like to get knighted by the Queen of England -- this happened because of IHI's quality improvement consulting with the British National Health Service (NHS). Here's what he told me:

"They called, the Consulate General in Boston. They don't just 'knight' you. They ask you -- here's how it goes. 'Dr. Berwick, if the Queen were to offer you a knighthood, would you accept it?' Because they want to kind of clear the way, and it could be insulting. So I said, 'Yes I would.' So that was the beginning. And for non-British citizens the actual procedure is not done by the Queen, it's done by the Ambassador of the country you're in. So I went to the British embassy in DC and there's a signed parchment thing and a seal, and these guys in uniforms walk out and hand it to you.

"And then you get the 'Knight Manual' -- there's a manual. And I don't remember what's on the first page, but at one place it says: 'Privileges of Knighthood.' One is: If you commit a capital crime, unlike commoners who are always hanged, you can get to choose. You can be hanged or beheaded.

"Actually it was an amazing experience, and I feel so grateful for it and so honored by it. And I know what happened -- IHI got invited to go to the U.K. in the late '90s to try and change care there, and it was a whole team. And it was a little embarrassing because there were about ten people who worked in the U.K. in that decade helping to make the changes."

Last evening, we had two remarkably divergent views on health care cost increases and the Affordable Care Act. First, here's President Barack Obama in his State of the Union speech:

"Already, the Affordable Care Act is helping to slow the growth of health care costs."

Pretty clear.  Then we have these comments from House Speaker John Boehner:

"Obamacare is driving up costs, jeopardizing coverage, and making it harder for small businesses to hire."

So who is right?

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On Monday, Ohio's John Kasich became the fifth Republican Governor to embrace the expansion of Medicaid, as permitted by the Affordable Care Act (ACA, Obamacare). "I think that this makes great sense for the state of Ohio," he said.

Of course, until last June 28, expanding Medicaid was not an option for states, and was included in ACA as a mandate. U.S. Supreme Court Justice John Roberts convinced a majority of his colleagues to make Medicaid expansion optional, the major change in the ACA from the Court's ruling, one I like to call the "Roberts Rule."

Last week, I was in Washington DC at the annual conference of Families USA, the national consumer health advocacy organization. In talking with folks from states now grappling with how to convince Republican governors and state legislators to expand Medicaid, I have developed a counterintuitive hypothesis for your consideration:

The June 2012 Supreme Court decision making the Medicaid expansion a state option will turn out, politically, to be enormously positive, perhaps even a game changer, for the future of the Medicaid expansion in particular and the ACA in general.

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