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What Is Past Is Prologue

Columnist: Kirk Pappas, M.D.
July, 2015 Issue

Kirk Pappas, M.D.
All articles by columnist

I’m always looking through the lens of history to provide some perspective on the future.

In 2009, I wrote an article for Sonoma County Medicine magazine, titled “A Mandela Moment in Medicine,” where I discussed the challenges in health care at that time: not a system; broken; unequal along socioeconomic lines with respect to access and quality;not focused on outcomes;driven by dollars rather than quality; and in desperate need of change.
When President Obama signed the Affordable Care Act (ACA; a.k.a. Obamacare) into law in March 2010, it was lauded as “the cure for what ills medicine.” But we professional observers of change were skeptical. Many have described the event as akin to LBJ signing the Medicaid and Medicare acts in 1965. What we forget, historically, is that it actually took 20 years for the state of Arizona to put Medicaid in place. Clearly, what we’re looking at now with the ACA is a process.
I’m always looking through the lens of history to provide some perspective on the future. In fact, the statue titled “Future” that stands outside the National Archives in Washington, D.C., is inscribed, “What is past is prologue.” That inscription provides a useful lens through which to view the ACA. Because it’s not the early adopters, but the early and late majorities who define how large populations of people adopt change. If you were the first to buy that clunky iPod with the whirring motor inside—when Apple stock was less than $25—then, like me, you’re an early adopter. But it’s the late majority of people who finally accept and adopt the change who drive the true societal acceptance of something new.
So where are we in adopting the ACA? It depends on the lens we look through. We know that the rate of uninsured in our nation has decreased from 16 percent to 12 percent in less than two years, and we know 14.1 million Americans have signed up through public exchanges.In California, emergency room visits are up more than 20 percent in most hospitals, and hospital beds are full. This increase in care is driven in part by the needs of all these newly insured residents.
We need only look through the Massachusetts lens for an example of what happened when it passed comprehensive coverage legislation nine years ago: There weren’t enough primary care physicians and there were challenges around access to care and increased use of emergency departments, operating rooms and hospital beds. However, today, Massachusetts has reversed most of those trends and is better able—not yet perfect—to manage the care of its population.
Another vital lens to peer through is that of individuals who now have insurance coverage through MediCal or Covered California. Many are extremely happy to have access to care and prevention. Yet they also face confusing issues around eligibility, “fines” for not buying insurance and complex deductibles and co-pays. In addition, they now feel the weight of this new health care “consumerism.” They can/get to or are forced to pick care like they would a flight to Los Angeles.
Another perspective is that of employers who face challenges around what they can afford to pay for employee health insurance. They’re no longer facing double-digit premium increases, but they’re not seeing decreases in costs, either. And they face the confusion of the private-public exchanges, accounting for each and every “employee month of service” while trying to stay in business and avoid penalties.
The majority of these challenges are still present because some of the changes that many of us sought (and, as I wrote about in 2009) have yet to be adopted. For example, changing from a “fee-for-service” reimbursement payment system to one that’s prepaid (which is actually how insurance works) would let us cover populations and share the risk and cost among millions instead of within a single family. Ninety percent of the physicians, hospitals and all the others responsible for your care in this nation are paid “fee-for-service” for the care they provide.
The current “fee-for-service” system drives quantity and more “stuff,” of which we know 30 percent adds no value to our health. Yet to drive the change around reimbursement to the delivery system and physicians, we must include paying for performance, specifically quality outcomes, service and prevention.
Despite all of these caveats and lenses, I’m extremely optimistic. As a physician, I know the right thing to do is find access to care for everyone within our nation. And as a leader, I know it’s difficult to lead through foggy weather and during confusing times. The saving grace, for me, is the fact that our country continues to move forward and address our challenges in our own way—as a process and not as a mere moment in time. I believe this journey is only starting and the last chapter will be written by the next generation of physicians and leaders.
So today, as we look to where we are in year two of the ACA, we need to both reflect on “what is past is prologue” and what Yogi Berra said: “We can’t predict the future because it hasn’t happened yet.” We’ll have to continue to learn from each other about what the right thing to do is for our patients, employees and community.
Kirk Pappas, M.D., is a board certified physical medicine and rehabilitation doctor. He’s the physician-in-chief of the Kaiser Permanente Medical Center in Santa Rosa.


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