At the recent American Association of Diabetes Educators (AADE) meeting, the Affordable Care Act and the changes it's bringing to our country's healthcare landscape were of course top of mind.
Our correspondent Wil Dubois was on the scene, having already filed reports on exhibit hall activity and the business side of diabetes education. Today, he reports on how the AADE conference handled the topic of healthcare reform -- bad news first, then good.
The epic changes in healthcare wrought by the Affordable Care Act (ACA) were both an official and unofficial thread that wound its way through nearly every session and hallway conversation at the recent American Association of Diabetes Educators (AADE) annual meeting.
On the official docket, sessions ranging from the keynote address to a breakout session entitled "Money Matters" dominated the schedule and more than 10% of the presentations dealt directly with insurance, healthcare reform, or money.
But in every session I attended (from a health literacy session to another on treating diabetic ketoacidosis in the Emergency Room) the sweeping changes in the healthcare landscape came up both in presentations and in the question-and answer sessions that followed. And it didn't stop there. In shuttle buses, hallways, bathroom lines, and even in bars (we go to no limits to bring you the news) changes in healthcare were on everyone's lips.
Surprising Dud of a Debate
A scheduled expert debate session held the promise of being the most riveting and informative offering of the official lineup, at least on paper. That session was titled, "Meet the Experts Diabetes Session—Affordable Care Act: Opportunities and Obstacles," and the expert participants were: Lucille Beseler of the Academy of Nutrition and Dietetics, Pamela Cipriano of the American Nurses Association, Ardis Hoven of the American Medical Association, and Jonathan Marquess of the American Pharmacy Cooperative. AADE President Joan Bardlsey served as ring master, moderating the session.
This brought together representatives of some of the most powerful doctor, pharmacist, dietician, and nurse organizations in the country. These are groups that in theory have many common interests, but have historically butted heads when their members' self-interests have collided. It should have been fodder for a lively discussion, but honestly I cannot recall being more bored in my entire life.
In essence, each expert read what amounted to a press release outlining the official stance of his or her organization. Then they all sat at a long table and took questions from the audience, rarely looking at each other, much less talking to each other — and certainly not debating. I confess I left the dry Q&A session early to avoid going into a narcoleptic coma.
Nonetheless, I did pick up a number of twitter-worthy pithy quotes and factoids worth passing along. Cipriano summed up the situation on the ground in healthcare, using the military acronym VUCA — Volatility, Uncertainty, Complexity, and Ambiguity. Well said, Sister. Remember that militaristic acronym dear readers, we'll use it again in a little bit. Beseler was more upbeat overall, saying she thought, "There are many opportunities ahead" for dietitians. But she repeated the grim mantra of proof-of-value by measuring outcomes by adding, "But if we are not able to gather outcomes, we're not gong to be here to deliver these services."
Marquess pointed out, quite correctly, that the ACA was unique in that, "you either love it or hate it, there's no one in the middle." But then he offered some interesting concrete tidbits, as opposed to the sweeping generalities offered by the other speakers. He shared that he'd found the cost sharing of medications "varies widely" from plan to plan, and that it's very hard for healthcare providers "to find the formularies" and know what drugs are covered and what drugs aren't covered for their patients. He's distressed about how many meds are finding their way into the brand-new, high-priced Tier 4 category — including the bulk of the front-line diabetes medications. He also pointed out the depressing fact that co-pays are set to rise under the ACA in the very near future, and adjustments in price caps could leave a family of four with an out-of-pocket healthcare tab of $12,700 next year.
That's about all I got out of that hour-and-a-half of my life I'll never get back.
One Rousing Speaker
But while the "great debate" was a great bore, there was a man who did not disappoint, and that was the previous day's keynote speaker at the official opening of the conference on Wednesday morning, the Bill Gates-esque Dr. Jonathan Oberlander, professor and Vice Chair of Social Medicine and Health Policy & Management at the University of North Carolina-Chapel Hill.
He was smart, funny, entertaining, and highly knowledgeable. He took us through where we are, how we got here, and where we are going in the ever-changing healthcare landscape. It's a story we should all know by now, but somehow don't. And Oberlander was somehow able to step back from the midst of the morass and provide some real-time hindsight, if such a thing is possible.
And how does Oberlander sum up American health reform? He says if it were a movie, it would be Ground Hog Day, and points out that our political leaders have been trying (and failing) to fix American healthcare for almost a century. Sure, we all know that Bill Clinton tried and failed, but he reminds us that so too did FDR, Harry Truman, and even Richard Nixon.
Setting the stage, Oberlander refreshed the audience's memory on where we were pre-ACA. In 2012, we had a healthcare "system" that cost $2.8 trillion, gobbling up 17.2 percent of the nation's gross domestic product, with one dollar out of every six in the entire economy disappearing into the black hole of healthcare.
The reality is that we had a "sickness insurance system" and not a healthcare system, one with "reverse incentives where success doesn't pay." He wondered what kind of healthcare system punishes people for success, and pointed out several programs that had been shuttered because they failed to make money -- only keeping people healthy.
Oberlander says the ACA's approach of building on the existing (broken) system is one that sounds good in "political theory" and it was engineered to be legislation that could be passed; but that's very different from building a system that will actually work. He says makes perfect sense, then, that some things worked out better than expected, and others were calamities no one could have predicted. Or in his words, "there were many surprises on roll-out."
Let's focus on what he had to say about two of the most polarizing aspects of the ACA: the Exchanges and the expansion of Medicaid.
The Health Exchanges
Oberlander said that the purchasing pool Health Exchanges originally had bi-partisan support, and, ironically, were the most popular part of the proposed reform before it passed, with 90% of people polled supporting it. But in the end only 16 states chose to build their own exchanges — a number far below what anyone could have anticipated — leaving the federal site to pick up a volume it was not engineered to handle. But despite the computer issues, the original signup targets were not only met, but exceeded.
Of the states that did build their own Exchanges, the quality varies a lot, with Oberlander saying that Kentucky did a "fantastic job," while the Exchange in Oregon is "horrible."
But — and this is in my words, not his — letting the Foxes build the Hen House didn't work out so well. Oberlander says many plans have deductibles that are too high, and restrictive networks that are "pricing people out of care." And as proof, he pointed to the recent New York Times piece about the cost of diabetes treatment for a woman who's fully insured.
As a side note, I can relate to this personally. My clinic recently adopted a high deductible/low DME coverage plan as a cost-saving measure. The result? Now I cannot afford both a CGM and an insulin pump. (This makes me want to cry because that custom Snap pump with the gray face and charcoal frame has been calling to me.) But as it is, I will end up fully paying out-of-pocket for the first eleven months of CGM sensors each year. Then the insurance will kick in and pay for half of the last box. That means for me that a pump, new or old, and its supplies, are out of the question. I work in healthcare for crying out loud, and I can't afford the standard of care!
Oberlander spoke to my heart when talking about the Exchange plans' emphasis on cost savings over anything else when he said, "The goal of the healthcare system should be quality outcomes," not just money saved. Rather, "our goal should be better and longer lives—and sometimes that requires money."
Too Little Medicaid Expansion?
While he didn't come right out and say it, I got the impression that Oberlander regards the Medicaid expansion as the largest failure of the ACA, and possibly the largest failure of our society since its inception -- not because expansion is bad, but because it isn't equally distributed or widespread enough. As we all know, the Supreme Court, while upholding most of the ACA, let states off the hook on Medicaid expansion. While this didn't gut the ACA like its detractors had hoped, it might have inadvertently set us up for the next Civil War.
Oberlander pointed out that there's a shocking similarity between the map of the Electoral College votes in the last election and the map of the states with expanded Medicaid. His big worry is what he calls "the huge inequity it causes. While 9 million more Americans are now insured, 60% of the Americans left uninsured live in states that didn't expand Medicaid."
"We are developing two Americas," he says, and has harsh words for the leaders of the states who opted out of expansion, saying that health insurance is a medical issue and not an economic issue. He cites the expansion as a prime example of how politics can trump common sense. According to Oberlander, less than half the states have adopted Medicaid expansion, even though doing so is financially beneficial for the states in both the short and long terms.
He accused politicians of "turning their backs" on the most vulnerable in their states. "Without expanded Medicaid," he said, "half the poor in the country can't afford affordable healthcare."
That might have been when he got the standing ovation.
Future Certainties and Uncertainties
Despite the political rhetoric from the Right, the ACA isn't going anywhere, according to Oberlander. He says too much water has gone under the bridge to repeal it, but that it could be "chipped away at" over the coming years, and he cautions us that debate is far from over.
But in the land of VUCA, we're about to become more VUCAified. Oberlander laid out the big unknowns that are looming in the coming months: In November it's enrollment time again. Insurers can raise rates. How will signups go? Do most of the people who most need insurance already have it? Could buyer's remorse lead to many people dropping out and not renewing, leaving the insurance companies with only the sicker populations, leading to yet higher premiums? Will there be a larger public backlash as the penalty for being uninsured rises? What happens if the employer mandate gets kicked down the road yet again?
If healthcare reform were a song, not a movie, says Oberlander, it would be Bob Dylan's The Times They Are A-Changin. But he remains optimistic. He says that as a society we have an opportunity to remake American medical care and that he believes that we are going in the right direction, but he adds: "We have a long way to go."
If such a distinguished scholar of past and present attempts to fix healthcare thinks we are on a good path, I couldn't help but become a little more optimistic myself. But it only lasted for a moment. Because Oberlander reminded me that even if the ACA had been fully implemented as designed (which clearly will never happen) it would still have left thirty-one million Americans behind.
That's all VUCAed up, in my book.
Hey, and speaking of the military, that's one thing I always admired about the Marine Corps: No matter the risk to the rest, they never left anyone behind.
Our nation should take a lesson in that.