A Culture of Coverage and Health Reform

(This month’s blog post is the text of an article that I was asked to write for a professional publication.)

As chair of the Iowa Tobacco Commission, I was responsible for helping to guide Iowa’s anti-smoking efforts by following a mission statement created by the Iowa Legislature that read “to foster a social and legal climate in which tobacco use becomes undesirable and unacceptable”. In this same vein of using legislation to create social change, I will review the actions derived from the Affordable Care Act (ACA), also known as Obamacare, in Iowa. From this family physician’s reading of the ACA, I submit that the underlying social change goal is to create a “culture of coverage,” which  means that within certain constraints, the citizens of the United States, and residents of Iowa in particular, will have the expectation that they have health coverage and that they will, in part, be responsible for securing that health coverage.

Obviously this 2,000 page law has many more elements, approaches, and objectives, but for me, this “culture of coverage” is the over arching goal. It is with this goal in mind, that I discuss what I perceive as the unfolding of the ACA in Iowa.

To be successful in creating a “culture of coverage” in Iowa, several requirements must be met. My short list of requirements that the ACA addresses includes:

  • Coverage must be accessible—think Exchanges.
  • Coverage must be available—think expansion of Medicaid and increasing competition in the marketplace along with federal subsidies to help pay premiums.
  •  Coverage must be sustainable—think care coordination, the Accountable Care Organizations (ACOs), and shared risk among policy holders, insurance companies, and providers.
  • Most important, health coverage must be required—think the combination of individual mandate and employer mandate.

One caveat. As a physician and long-time public policy wonk, I fault the ACA for not having a meaningful tort reform element present in the legislation. That said, I would like to outline how I perceive that each of these ACAs elements effect Iowa.

As of October 1, the Iowa Exchange, also referred to as the Marketplace, allows Iowans to buy health insurance, some at subsidized rates based on an individual or family annual income, as well as allow other Iowans to sign up for Medicaid. In Iowa the Exchange is called a hybrid or partnership Exchange because both the federal government and State of Iowa are managing different aspects of it.

Enrolling for insurance coverage can be accomplished in one of four ways:

  1. Directly: an individual can access the Exchange via a computer, complete a paper application, or apply via telephone
  2. With help: an individual can use an insurance agent
  3. With help: an individual can use a vigorously trained layperson called a Navigator
  4. With help: an individual can use a trained, certified layperson called a Certified Assistance Counselor (CAC).

Steps 1 and 2 are self-explanatory but the other steps involve individuals in newly created positions. Navigators are employees of entities who have received Federal grants to pay for this service. In Iowa, three entities—Genesis Health System in eastern Iowa, Visiting Nurse Services, and Planned Parenthood—received grant monies to serve certain counties. Unfortunately, 27 counties, mostly in northern Iowa have no access to Navigators. CACs are volunteers representing various entities including hospitals, physician groups, community health systems, community organizations, and others trained by the federal government to provide assistance to individuals who want to apply for coverage on the Exchange. In my clinic in Ames, my health coaches are CACs and provide this service for my clinic patients. A list of available Navigators and CACs in various Iowa counties is available on the healthcare.gov website.

Regarding health coverage options, the grand bargain to which the Iowa legislature and governor agreed this spring allowed for expansion of Medicaid with some changes and specific requirements for individuals making less than 100 percent of the Federal Poverty Limit (FPL) and for individuals making between 100 and 133 percent of FPL. Those individuals would be enrolled in private insurance through the Exchange paid for with Medicaid Expansion funds. I supported this bargain because I believe that by and large, individuals who make less than FPL have different requirements, needs, and resources that would make Medicaid the more reasonable source for health coverage; likewise, for individuals at the higher income levels who work side-by-side with individuals who have private insurance, they would be better served with private insurance.

For individuals signing up for private insurance within the Exchange, there are two state-wide insurance offerings: Coventry and CoOportunity Health, a new insurance cooperative established using start-up loans from the federal government under the ACA. The new cooperative is also offering insurance in Nebraska and is the only ACA-funded health insurance cooperative to serve residents of two states. I served on the federal advisory board that suggested rules for administering the newly established cooperatives at the federal level. The new co-ops, based on the rural examples of grain co-ops and rural electric co-ops, offer a new approach to providing insurance because it will create partnerships among policy holders, providers, and insurance companies that will yield better care at lower costs.

Sustainable is the make or break element of the entire health care universe. How do we afford health care in the future?  The ACA envisions a reliance on care coordination: at the micro level, it supports efforts such as the patient-centered medical home (PCMH). In Iowa, this coordnation is referred to as Health Homes for Medicaid purposes), and at the macro level, Accountable Care Organizations (ACOs) are envisioned for Medicare. Iowa has seen a recent flurry of activities regarding both patient-centered medical homes and ACOs. The data are now overwhelming that care coordination at the primary care level works. In states including Vermont, Massachusetts, and Utah, and in parts of New York, the cost curve has been bent by groups using the tenets of patient centered medical homes, especially when primary care physicians have access to data regarding patient use of MedicPal services at the point of patient contact. Regarding ACOs in Iowa, we now have integrated health care systems, multi-specialty clinics, and primary care clinics willing to consider taking risks in order to care for a patient population with the win-win goal that all parties will enjoy improved quality of care and cost efficiency. Which of these approaches are the most viable for ACOs remains to be seen.

Finally, the current debate in Washington centers on the individual mandate. I believe that the individual mandate is required because that is the only way to eliminate patients being excluded from insurance coverage due to pre-existing medical conditions. I served on two Iowa legislative health care commissions and each of those commissions had a high-level health insurance executive as a member. Both executives said that the only way to eliminate exclusion of  pre-existing conditions was with an individual mandate.

In summary, the ACA seeks to create a “culture of coverage” by undertaking several major changes in our health care system. These changes attempt to make health coverage accessible, available, and sustainable. Sorting out the actual effects of this law in Iowa regarding patients, providers, and society will be left to other commentators three, five, and ten years from today.