Op-Ed Columnist

Obamacare: The Rest of the Story

By BILL KELLER

Published: October 13, 2013 

Unless you’ve been bamboozled by the frantic fictions of the right wing, you know that the Affordable Care Act, familiarly known as Obamacare, has begun to accomplish its first goal: enrolling millions of uninsured Americans, many of whom have been living one medical emergency away from the poorhouse. You realize those computer failures that have hampered sign-ups in the early days — to the smug delight of the critics — confirm that there is enormous popular demand. You have probably figured out that the real mission of the Republican extortionists and their big-money backers was to scuttle the law before most Americans recognized it as a godsend and rendered it politically untouchable. 

 

Tony Cenicola/The New York Times

Bill Keller

What you may not know is that the Affordable Care Act is also beginning, with little fanfare, to accomplish its second great goal: to promote reforms to our overpriced, underperforming health care system. Irony of ironies, the people who ought to be most vigorously applauding this success story are Republicans, because it is being done not by government decree but almost entirely with market incentives. 

Using mainly the marketplace clout of Medicare and some seed money, the new law has spurred innovation and efficiency. And while those new insurance exchanges that are now lurching into business will touch roughly 1 in 10 Americans (the rest of us are already covered by private employer plans or by government programs like Medicare), these systemic reforms potentially touch every patient, every taxpayer. 

“This is the 90 percent of the story that doesn’t make the headlines,” said Sam Glick, who follows health care reform for the Oliver Wyman consulting firm. 

Since the Affordable Care Act was signed three years ago, more than 370 innovative medical practices, called accountable care organizations, have sprung up across the country, with 150 more in the works. At these centers, Medicare or private insurers reward doctors financially when their patients require fewer hospital stays, emergency room visits and surgeries — exactly the opposite of what doctors have traditionally been paid to do. The more money the organization saves, the more money its participating providers share. And the best way to save costs (which is, happily, also the best way to keep patients alive) is to catch problems before they explode into emergencies. 

Thus the accountable care organizations have become the Silicon Valley of preventive care, laboratories of invention driven by the entrepreneurial energy of start-ups. 

These organizations have invested heavily in information technology so they can crunch patient records to identify those most at risk, those who are overdue for checkups, those who have not been filling their prescriptions and presumably have not been taking their meds. They then deploy new medical SWAT teams — including not just doctors but health coaches, care coordinators, nurse practitioners — to intervene and encourage patients to live healthier lives. 

Advocates of these reforms like to say that they are transforming medicine from the treatment of disease to the treatment of patients — and ultimately the treatment of populations. 

At Cornerstone Health Care, a 250-doctor organization in North Carolina, patients with a history of congestive heart failure get a daily phone call from a nurse asking them to step on a scale and report their weight, the best early indicator of an impending emergency. The next stage, Grace Terrell, the president of Cornerstone, told me, will be to give these patients scales that automatically transmit their weight directly to the nurse. (“If the N.S.A. is Big Brother, we’re Big Mother,” Terrell says of the weight surveillance program.) Diabetes patients are invited in for low-cost pedicures. Why? Because diabetics are notoriously vulnerable to infections that lead to amputation, and a common cause of those infections is ingrown toenails. (Both of these practices were pioneered by CareMore, a California-based company that runs clinics for Medicare patients and that has become a major role model since Obamacare.) 

The Heritage Provider Network, a huge accountable care organization in California, offers Medicare patients free dance lessons, healthy cooking classes and casino excursions that feature “brain power” activities on the bus. The Greater Buffalo United Accountable Healthcare Network, a new, seven-doctor practice in upstate New York, is building a gym and a teaching kitchen for its patients, who are mostly inner-city minorities. 

“Most doctors were on treadmills,” plodding through their routines, said Raul Vazquez, the chief executive of the Buffalo venture. Now they’re reinventing health care for the inner city with an invigorated sense of mission. 

This is not the heroic medicine that turns surgeons into gods and emergency rooms into Hollywood material. Don’t expect to see a toenail-clipping episode on “Grey’s Anatomy.” But these services address the embarrassing fact, reiterated in study after study after study, that Americans pay much more for medical care than other developed countries, with no better results. 

Obamacare addresses this problem by going, as Willie Sutton famously advised, where the money is. It concentrates resources on the unhealthiest. According to Kaiser Health News, the sickest 1 percent of patients account for 21 percent of health care costs; 5 percent account for half of the total costs. 

“There are organizations that are bringing emergency room visits down by 15 to 20 percent,” Glick said. “Hospital admissions, you see numbers like 20 and 30 percent. That can make a huge difference not only in the cost of care but also in the quality of care.” 

The best sign that these innovations are beginning to go viral is that they have caught the attention of some giant businesses. Drugstore chains like Walgreens and CVS are now partnering with hospitals or accountable care organizations to give patients convenient points of access and to coordinate treatment. Companies that spend heavily on employee health care plans are learning the best lessons of the Obamacare laboratory. Walmart, the country’s biggest private employer, will fly workers who need transplants or heart or spinal surgery to premier facilities like the Mayo or Cleveland Clinics to assure that their problems get fixed right the first time, avoiding costly readmissions. 

Obamacare has also had some important indirect consequences. According to Catherine Dower of the Center for the Health Professions at the University of California at San Francisco, since the Affordable Care Act states have become more aggressive about challenging some of the protectionist laws that prevent well-qualified medical professionals — pharmacists, nurse practitioners, physician assistants, emergency medical technicians — from offering some kinds of primary care. California just passed a law that will allow pharmacists to check your blood pressure and cholesterol level and to dispense prescription birth control and antismoking drugs. Letting pharmacists perform services that don’t require seven years of medical training makes those services cheaper and more convenient, increasing the chances consumers will take better care of themselves. 

Dower said that while the formal doctor lobby continues to resist this as a threat to the M.D. cartel, many physicians have embraced it, recognizing that outsourcing some of these services leaves them more time to do what only doctors can do. And with an estimated 29 million new clients expected to join the ranks of the insured, there is a lot of work to share. 

The emerging system is far from perfect. As Elisabeth Rosenthal reported in The Times on Sunday, Congress buckled to drug company lobbying and refused to let Medicare use its purchasing power to bring down obscenely inflated drug prices. And like any upheaval, the reform of health care will produce some losers. Not all of the new organizations will make a go of it. Since hospitals account for about a third of our health care bill, they are a particular target of cost-cutters; some will fail to adapt and will go out of business. Taking costs out of the system means taking money out of somebody’s pockets. This is what the business world calls “creative destruction.” 

Grace Terrell of Cornerstone said that of its 250 doctors, “20 percent are still, ‘Down with Obamacare,’ though even they like the private-enterprise approach; 30 percent really get it; and the others are moving faster than the market. We may ultimately fail, but we’re pretty far ahead of the curve.” 

One reason you may not have heard much about this part of the Obamacare story is that it is numbingly complicated. (Stephen M. Davidson of Boston University has written a concise and accessible guide to the law and its consequences.) But I suspect another reason is partisan spite. The Democrats were passionately in favor of enrolling the uninsured, but many would have preferred a government-run program, or at least a public option. What Obamacare has wrought is the kind of market-driven reformation that Republicans pretend to believe in. Which makes you wonder how much of their opposition rests on the merits, and how much is just a loathing for anything associated with Barack Obama.