The changes began to appear in the final two quarters of 2014. By mid-2015, the movement to increase access to health insurance seemed established enough to appear to be a trend. Some of these developments were publicly reported: percentage of lives covered overall, numbers accessing coverage through the exchanges, and trends that seemed to indicate that costs were holding constant, and if not, then perhaps bending away from increasing. There was active discussion over validity, meaning, and, of course, causality. Were these developments a function of the Accountable Care Act (ACA) or a reflection of a deep recession followed by a fairly long-running recovery? Other changes were less obvious to the general public and too small to account for a trend: a large delivery system in the Midwest reporting that after three years, over half of new appointments were being made online and that consumer satisfaction with its service was up 22 percent; a major East Coast medical school’s OB/GYN department announcing that by 2020 it planned to have 80 percent of its births assisted exclusively by a nurse midwife; and, a large medical group in California incorporating a collaborative approach between primary and specialized care, coupled with advance directives and palliative care as it improved the quality of end-of-life experiences for patients and their families.
The system was so large—comprising almost 20 percent of the nation’s productive effort— and famously segregated into silos governed by a complex and at times conflicting set of state and federal regulations and funding, that it was hard to see that the policy changes of universal coverage, global payments to providers, and consequences for outcomes that had been established with the ACA had been deeply, if not perfectly, aligned with the broader changes that were driving themselves through society. These changes included an aging population, growing consumer demand for more control and responsibility, anxiety over the cost of care, and dramatic changes in work and life driven by information technology. The alignment between these two pivotal changes was producing the synergy needed to rework the system from the bottom up, not to dictate the changes from the top down. With a pending Supreme Court review of the legality of subsidies from states without their own purchasing exchanges in mid-2015, Chief Justice Roberts again voted with the majority to sustain the efforts of the essential reforms.
On the heels of this ruling that was, in the end, seen as more technical than landmark, many Republican-dominated states began to acknowledge that their fiscal and physical health could only be addressed by using a revived and restructured Medicaid program to provide universal coverage in their states. Without such a state policy in place, they would be trapped supporting the old variegated and disconnected arrangements for care that were increasingly expensive and produced inferior outcomes. The contrast to those states that covered nearly all of their citizens through revamped insurance markets and subsidies became increasingly stark.
As the economic and health advantages of integration became more obvious, several states realized that the regulatory infrastructure that had been built up around health and health care no longer served the interests of their citizens. These states were the first to experiment with a new structure that looked at finance, delivery, and population health with policy, operational, and oversight dimension in each area. The states could then set health goals tied to outcomes and effectively focus all public and private resources on meeting these goals. The reduced duplication allowed policymakers to know what worked, allowing them to push for change in the ‘system’ to move along faster.
Once these states had the whole picture in front of them, they could focus on global budgets and aligning state policies to with the direction of the change. The shortage of primary care providers disappeared as physician assistant and nurse practitioner practice acts were rewritten to expand access. Many other parts of health care delivery were deregulated because now, a single oversight body could more effectively guarantee performance and public protection. This also allowed states to more effectively plan for longer-term changes as society aged, information technology proliferated, and the nature of work aligned itself with the shifting global economy.
Perhaps the most significant change in states came about as the population covered with health insurance approached 90 percent, which was reached by early 2015. At this point, just about everyone had public or private health care, and the burden of financial risks coming from catastrophic or chronic health problems was no longer borne by individuals. Primary prevention then became of significant interest to these insurers. An emergency room admission for a drive-by shooting has always been a tragedy for the family and patient, but now some other entity would be responsible for the hundreds of thousands of immediate and long-term costs. In this world, effective public safety for all neighborhoods, employment, and improved education became of interest to large, powerful, and well-resourced organizations.
This change of focus from downstream treatment to upstream prevention led to changes in public policy and a realignment of resources. The shift began to increase support for public policy changes not only in public safety, but also in education, housing and income security as well. These changes not only improved life, more importantly they ‘compressed’ morbidity leading to fuller more productive lives that were not burdened by health care maladies and costs.
Thinking of care in this manner allowed for the development of new approaches to how chronic diseases were managed. In the traditional system, the most expensive part of the health care system, the hospital, was the place where most people with chronic diseases were provided care. Increasingly the value of providing new services in the community and home that kept patients healthier and lowered the use of expensive acute-based services, proved effective for overall costs and outcomes and desirable for individual consumers.
The successful evolution of the US approach to health care did not come exclusively from either the political left or the right. The left promoted universal access, control of excessive profiteering, and more population-based approaches to social welfare, including health and health services. Meanwhile, the right encouraged innovation, often driven by entrepreneurial action, appropriate deregulation, and competition that could deliver lower cost services that were of higher quality and more responsive to customer needs. These mutual contributions worked best in those states that lowered the competitive political rhetoric and focused on mixed solutions. Those states that focused on addressing immediate problems with caring and creativity were able to break through the constraints that had driven the old arrangements of care and provide better service, to more people, and at increasingly lower costs.