Hallelujah! Hallelujah! Hall-e-lu-jah! The Supreme Court has affirmed the Individual Mandate! The Court has supported the Medicaid Expansion!
Clearly, in making this decision the Supreme Court has followed some key principles enshrined in our defining national documents. Our Declaration of Independence seeks independence in order to "promote life, liberty, and the pursuit of happiness." The preamble to our Constitution seeks to "promote the general welfare." Promoting life, the pursuit of happiness, and the general welfare are intimately related to good health: none are achievable without it. Hence, a very strong basis exists in the earliest documents of our country for our national government to become engaged in actions that promote the good health of all Americans.
The 14th Amendment to the Constitution guarantees equal protection under the law for all Americans. A restatement of this protection is "we value all people equally." This is a clear basis for the dictum of social justice in our civic life. In healthcare, this can be interpreted to mean that our national government has the obligation to undertake efforts to reduce health disparities by actions that promote and maintain equity.
When we combine the principle of good health as a basic concept and the dictum to promote equity, we have a very, very strong basis for arguing that our national government must undertake national health reform efforts to foster the conditions under which life, happiness, and the general welfare can actually be pursued. In fact, it is precisely to promote these goals that the United States of America was formed originally!
Now, we must press ahead with core reforms in care delivery that are already underway. Catalyzed by the affirmation of the Affordable Care Act (ACA), these reforms will be critical to the care delivery system that is now taking shape. These reforms certainly will be with us as we prepare to move into the third decade of the 21st Century.
The principal foci of the ACA are coverage and access. In fact, both features of the Supreme Court case--the individual mandate and the Medicaid expansion--are about these issues. The ACA gives much less attention to the actual configuration of care delivery going forward. Yet, a few moments reflection will help you realize that health reform can be done by insurance expansion and care reconfiguration. Let me expand on that idea a little further.
By "care reconfiguration," I mean how we approach the factors of service delivery, who delivers the care, how we combine our organizational resources, and how we allocate our available dollars. At the moment, all of these things are in rapid flux. Each of these factors is being shaped by a number of larger movements, which I would like to explore in greater detail, since they do not always get a lot of attention. These movements include:
1) Movement toward "whole health" and person-centered care. Most administrators realize intuitively, if not operationally, that care of the whole person in a single place is more effective and less costly than piecemeal care delivered from multiple, separated programs. Thus, the pace of organizational change is accelerating, like snow in an avalanche. Some organizations and hospitals are purchasing others, new inter-organizational arrangements are emerging, other hospitals are partnering with primary care practices, and other primary care practices are working closely with community behavioral health entities. These consolidations are likely to result in better quality integrated care, with overall cost savings per person served.
Similarly, health administrators now recognize that care providers have a major role to play in disease prevention and health promotion. Like whole health, this realization is producing tumultuous changes in the actual care that is being delivered. What would have been thought to be virtually impossible just a short time ago is now commonplace: wellness clinics are emerging, healthy promotion groups are becoming common, and people are taking personal responsibility for their own health. …