Love it or hate it, the health care overhaul is the most significant piece of domestic legislation to emerge from Washington in decades. The new law is also ferociously complex: The original Senate bill, which served as the blueprint for most of the changes, ran well over 2,000 pages. So what is buried in those pages? Here are some thoughts from health care experts on what the changes will mean for Americans, sick and well alike.
Joel A. Strom
M.D., professor of internal medicine and honors college, University of South Florida
making it cost-effective: Health care reform promises to improve the health of the American citizenry by simultaneously increasing access to care while improving the efficiency and cost-effectiveness of its delivery. A hoped-for byproduct of reform is a reduction in the current large geographic variance in care costs unassociated with demonstrable outcome benefits as documented for Florida Medicare beneficiaries (www.dartmouthatlas.org). That said, a number of barriers persist to reducing variance of care costs: race, socioeconomic status, employment rates, prevalence of certain diagnoses (pre-existing conditions, severe chronic diseases, or catastrophic illnesses), uneven distribution of manpower and resources, practice patterns, and inappropriate resource utilization by both patients and health care providers.
To achieve universal, cost-effective health care while reducing regional cost and outcome disparities will require collaboration of all stakeholders: consumers, employers, insurance providers, health care providers and the political leadership. Realigning resources and ending the duplication of services can only be attained by bringing all of the stakeholders together. Florida is fortunate in this regard. There are already statewide efforts addressing cardiovascular and trauma care that can serve as paradigms for this process.
Michael D. Aubin
Administrator, St. Joseph's Children's Hospital, BayCare Health System
hope for children's health: As the state of Florida's largest provider of pediatric hospital services, we embrace health care reform. We expect it ultimately will allow more children and families in our community to receive medical services they need without the risk of financial instability. Our hope is that elected officials keep two important issues in mind: access to specialty care and adequate Medicaid payment to children's hospitals.
Access to care will improve when pediatricians and pediatric specialists can cover the costs of seeing Medicaid patients. This legislation is a step in the right direction. The legislation also will prevent insurance companies from refusing to cover children with pre-existing conditions, which is very important for families.
Our hope for the future is that hospitals are adequately reimbursed by Medicaid, which currently does not cover the costs of providing care. With more children directed into the program, hospitals will bear an increasing financial burden unless they are paid for services they provide.
By improving access to the doctor's office and providing better insurance coverage, children and families have a better chance to live healthier lives.
Elizabeth A. McGlynn
Associate director of health programs, RAND Corporation
ALL THOSE NEW CUSTOMERS: Can the health care system handle the demands of 30 million-plus new customers?
It's estimated that more than half of the newly insured will be under age 35, and about 80 percent will be in good to excellent health. They will not be using services for the first time, but they may decide to change providers. More than one-third will enroll in Medicaid, and it's thought they will use fewer services than those with private insurance.
Still, in the short run, the capacity of the system to meet demand will be strained, particularly in areas that currently have high rates of uninsurance.
Consumers shouldn't be surprised to find a system in flux as we look for new ways to deliver health care. Patients might see a nurse practitioner instead of a doctor for routine problems; they might confer with their doctor over secure Web sites or their cell phones. We're likely to see health care delivered in ways we've never seen before.
Michael D. Tanner
Senior fellow, Cato Institute
no help on premiums: It's not just what the bill will do; it's also what it won't do.
It won't do anything to lower premiums. Insurance premiums will roughly double over the next six to 10 years for people with group coverage through work, just as they would have without the legislation. For nearly 37 million people in the individual insurance market, the new minimum package of benefits means that they can expect to pay 10 to 13 percent more than they would have if the bill hadn't passed.
About 57 percent of these workers will receive at least some subsidies to help offset the cost, but 43 percent will have to bear the full cost. True, they will receive more benefits, but it will not be by their choice.
Henry J. Aaron
Senior fellow, Brookings Institution
COULD TAKE A GENERATION: Everyone should recognize that there will be no parting of the heavens. Changes in a $2.6 trillion industry will not come quickly. For the immediate future, the number of uninsured will most likely keep on rising. Spending will keep increasing at excessive rates. The quality of care will not be instantly transformed.
But a process of reform that will take a generation to unfold must begin now. And that requires a sustained effort by health reform supporters to explain to the public what is in the bill and to clear away misconceptions created by opponents.
Consumers stand to gain enormously from efficient, well-designed health insurance exchanges. But state officials opposed to reform may well stall and create roadblocks. So supporters should mobilize now to see that as many states as possible move promptly to enact the laws necessary to create these exchanges.
Timothy Stoltzfus Jost
Professor, Washington and Lee University School of Law
OPPORTUNITY FOR THE STATES: Health care reform is now the law of the land. But most of the insurance reforms, including the consumer protections and exchanges, must be implemented by the states. The law asks states to adopt the federal standard or their own equivalent standards. The federal government will enforce the law's requirements or set up a health exchange only in states that choose not to do so.
This is a real opportunity for the states, and in particular state insurance commissioners, to design approaches that fit their own situations. But there is also a threat to consumers if states adopt laws that do not measure up to the federal standards. It is unfortunate that a quarter of the states have started off on the wrong foot, challenging the law rather than working with it creatively to serve their own citizens' interests.
William H. Dow
Associate professor, University of California, Berkeley
WHY PEOPLE GET SICK: Expanding health insurance to 32 million more people will greatly strengthen our country's safety net. The reforms will also improve the health of many of those currently uninsured, addressing a national disgrace: the premature deaths of uninsured people who cannot get medical care.
But inadequate health care accounts for just 10 percent of premature mortality. Even with these reforms, our populationwide health indicators will continue to trail those of other developed countries.
Significant improvements in life expectancy will require turning our attention to underlying social determinants that lead people to fall ill in the first place. The next major social policy fight should concentrate on the single most important factor that research suggests will improve the health of the next generation: investing in the education of disadvantaged youth.
President, Commonwealth Fund
GOOD NEWS FOR YOUNG ADULTS: Young adults are likely to feel the most immediate impact of the legislation. They constitute 19 percent of the uninsured, and among those without insurance, two-thirds report problems getting access to care and half report problems with medical bills or debt.
By September, young adults will be allowed to remain on their parents' health plans up to age 26. And starting in 2014, Medicaid will be available to all adults with income at or below 133 percent of the federal poverty level — 7.1 million uninsured people ages 19 to 29. In addition, they will be able to buy coverage through health insurance exchanges, where two-thirds of young adults (those with incomes below four times the poverty level) will receive help paying premiums and medical bills.
With secure coverage, I think many more adults starting out in life will feel free to follow their dreams rather than the safe road to jobs that offer health benefits.
Administrator, Health Care Financing Administration, 1990-92
WAITING FOR 2014: Many of the uninsured are going to be unpleasantly surprised that new insurance options for them remain years away — 2014, to be precise.
That's the year insurers will have to take all applicants regardless of pre-existing conditions. Everyone earning less than 133 percent of the poverty line ($14,404 for a single person) will be eligible for Medicaid. People who aren't offered employer-sponsored insurance whose income falls between 133 percent and 400 percent of the poverty line, and who aren't already on a public program, will be offered subsidies to choose among negotiated insurance plans through state-organized insurance exchanges.
Some benefits, primarily for limited groups of individuals, will be available later this year: Some young adults will be able to stay on their parents' plans, and people who have been deemed uninsurable will be able to buy insurance through subsidized high-risk pools. These are not trivial benefits, but they are not relevant to most of the uninsured.
Unlike the benefits, much of the financing starts before 2014. Consumers will feel those effects directly and indirectly. Health insurance premiums are likely to rise, and many seniors who have been on Medicare Advantage plans are going to find their benefits cut or premiums raised, since almost 30 percent of the Medicare cuts come from reductions in payments to these plans. We'll have to see whether promises of more benefits in the future will outweigh the short-term pain.
Jacob S. Hacker
Professor political science, Yale University
A NEED FOR COMPETITION: Perhaps the most attractive promise of reform is that if we lack or lose coverage, we'll have the security of knowing we can buy affordable insurance through the exchanges set up by the states. This promise won't be effectively realized, however, unless state and federal leaders charged with setting up the exchanges are pressured to keep private insurance premiums in check.
After all, 99 percent of local insurance markets are "highly consolidated," according to the American Medical Association, and in 24 states (up from 18 a decade ago), the largest insurer has more than 70 percent of the market. At a minimum, strong exchanges will be needed to encourage competition and transparency.
Even better, consumers should demand a public insurance option that would compete with private plans — immediately cutting 10 percent off the average private premium, according to the Congressional Budget Office, and saving the federal government more than $100 billion over 10 years.