- Photo illustration by Susan Kruithof
An apple a day keeps the doctor away—but unfortunately for apple-eating Americans, U.S. health care has made its money not on keeping people away from the doctor, but on the costly emergency-room visits, scans and surgeries that occur when people avoid the doctor until the very last minute. Now, though a June Supreme Court decision declared that President Barack Obama’s Affordable Care Act has passed its constitutional checkup, Utah is waiting to see who wins the presidential election in November before it embraces wellness programs and other optional ACA components.
Utah Gov. Gary Herbert’s health adviser, Norm Thurston, argues that if a Mitt Romney administration takes power, the new regime could possibly muster enough support to repeal ACA, or at least give states greater flexibility to expand Medicaid, which provides coverage to low-income citizens, using some components of ACA but not others.
But Judi Hilman, director of the nonpartisan Utah Health Policy Project, worries that for Utah to wait until after the Nov. 7 election to take its medicine, the state is hurting its chances of learning the best ways to provide efficient wellness initiatives. She points out the ACA has grant applications to allow Utah to take part in learning communities that are using evidence-based research on the most effective ways to keep insured populations healthy and away from the surgeon’s scalpel—following the “apple a day” strategy rather than the “wait till something explodes inside me” strategy.
Expanding Medicaid and changing delivery from paying for patients’ wellness to paying for individual services was something Utah officials wanted back in 2007, after then-Massachusetts Gov. Romney rolled out similar reforms in his state. Hilman sasys politics are now standing in the way of the Utah fully embracing “an apple a day” thinking.
“Why was it OK then and not OK now?” Hilman asks. “I can only come up with one answer—it’s now linked with Obamacare. What it’s about now is bringing Obama to his knees.”
The Supreme Court decision offered a mixed bag to critics of the 2010 health-care reform. While the justices upheld the most controversial aspect of the bill—the individual mandate that requires Americans to have health insurance or pay a tax—they also ruled that states could not be penalized for not expanding Medicaid in the manner ACA recommended. Now, states like Utah are grappling with whether or not to expand Medicaid. Under the ACA, the expansion of Medicaid programming would be covered 100 percent by the federal government for the first three years; after that, the state would be on the hook for covering 10 percent of costs. Currently, Medicaid is funded 70 percent by the federal government and 30 percent by the state.
But the number of Utahns eligible for, but not currently enrolled in, Medicaid is a factor worrying Utah officials. According to a study by the Kaiser Commission on Medicaid & the Uninsured 2012, under ACA, Utah will have 78,284 newly enrolled people in Medicaid by 2019 who were previously eligible but not covered.
At a July 19 meeting of the Utah Legislature’s Health System Reform Task Force, lawmakers were eager to hear what health adviser Thurston had to say on state Medicaid expansion. The essential answer was “wait and see.” Thurston noted that the language of the ACA grants greater latitude to the director of the U.S. Department of Health & Human Services about how much of the expansion states can adopt.
“If HHS comes out strong and says on the Medicaid expansion, ‘No, there’s no flexibility, it’s all or nothing,’” then, Thurston says, the state would lean more toward turning down the expansion. “But I’m pretty sure if we get a different president, then there would be a lot more flexibility.”
Hilman sees that move as shortsighted, considering the cost savings that could come from some of the ACA’s incentives for wellness and preventative health care. Bringing the majority of the uninsured under coverage will lead providers to move toward “an apple a day” strategy, but beyond that, Hilman says, the ACA has specific grants that can help the state improve preventative care and wellness programs. One
specific expansion in the law are health-care “quarterbacks”—primary-care providers at a central base for each patient who map out different health choices for the patient, instead of simply diagnosing a problem and then sending the patient to a specialist.
So far, the governor’s office has suggested that it will simply continue to study the offer and will not propose a plan for expansion to include the elements Utah does and doesn’t want, choosing to wait to play any and all cards after the election in November.
Hilman, who’s part of the advisory committee for Accountable Care in Utah, the group helping with the implementation of Utah’s health-care exchange, says this wait-and-see approach has also put on hold that group’s efforts to define quality measures for evidence-based “apple a day” wellness measures.
Hilman says the plan from earlier this spring involved having a litmus test for preventative-care plans, backed up by leading research, but this guiding standard has been put off by the state Medicaid office.
“If we’re trying to guide the market about meaningful choices, then we’ve got to have some objective criteria for comparing [wellness programs],” Hilman says.
Dave Patton, director of the Utah Department of Health, says that Utah is already moving forward with preventative care and wellness as part of its 2011 Medicaid reforms. In 2013, Utah’s Accountable Care Organizations will assume full risk for Medicaid clients and are moving forward with strong wellness-centered programs, Patton says.
“That’s all going live Jan. 1, 2013,” Patton says. “Wellness programs and preventative measures are going to be implemented for all the ACOs [that administer Medicaid] in January.”
While Hilman is excited about what Utah’s reforms will do, she still is disappointed that the state is helping to implement wellness programs before they’ve established guidelines on which “apple-a-day” wellness programs actually work best. Patton, however, says the standards are still being developed and that discussion is ongoing.
Hilman worries that the state’s procrastination on submitting proposals to the feds about Medicaid expansion and tarrying in developing across-the-board wellness standards is not “apple a day” policy thinking, especially when leaders shirk setting policy for fear of rising costs.
“The answer is not to just say ‘no’ and not pay, but to dig deeper into accountable care with better quality measures and better transparency,” Hilman says. “If you do that well, then you’re going to [cut out] the 20 to 30 percent of health cost that has no value—the waste.”