"What to Expect": Health Care Access in an Era of Institutional Transformation, Adversarial Politics

The 25th National Conference on Primary Health Care Access will convene at the Hyatt Regency San Francisco Monday morning April 14, 2014. Its distinguished faculty will include knowledgeable professionals engaged in health care delivery, health sciences education, and health policy.

A night time view of the San Francisco Ferry Building viewed from the Hyatt Regency San Francisco
A night time view of the San Francisco Ferry Building viewedfrom the Hyatt Regency San Francisco

The conferences over the past quarter century have been concerned with major health policy initiatives, their successes and failures and, at times, unintended consequences. [See “What to Expect!”: the Theme of the 25th National Conference on Primary Health Care Access.]

The most significant legislative effort during this period was the passage of the Patient Protection and Accountable Care Act  (PPACA).

At the time of its passage, some members of our permanent faculty raised issues about whether the legislative process yielded the best results.

Some believed that totally different financing mechanisms, such as adopting a universal health plan, expanding Medicare to all, or funding the safety net directly or through mechanisms such as federalizing Medicaid, or adopting a universal health plan, would have the end result of a more smoothly functioning health care system, minimizing both health care and administrative  costs.

The Regency Club View of San Francisco Bay
The Regency Club View of San Francisco Bay

Others found great merit in various features of PPACA, seeing it as a catalyst for the kinds of institutional changes that would bring about improved community health and increased access to primary health care.

Even some of the act’s admirers raised concerns about our current systems of educating physicians, and suggested that the new legislation might prove difficult to implement given the nation’s geographic and specialty maldistribution of health care professionals and inadequancy of institutions to meet the challenge of increased patient loads.

The Hyatt Regency Atrium
The Hyatt Regency Atrium viewed from an upper floor

Now three years after passage, it is clear that the act is proving more difficult to implement than was originally imagined.

That difficulty is exacerbated by the failure of the act to secure the high degree of public support needed to prevent it from becoming the subject matter of partisan politics.

Unfortunately, for those who wish to see PPACA implemented expeditiously and without controversy, the approximately even split of power between two political parties creates a problem for PPACA, since its passage relied virtually exclusively on one party.

In recent years both houses of Congress have been up for grabs every two years and as has the presidency every four years.

As implementation of PPACA began, the party in opposition detected sufficient discontent with specific provisions of the act to make it a centerpiece of its 2014 election campaigns.

The 2014 elections are crucial to both parties because both Congressional houses might be in play, so there is diminished enthusiasm from members of the party in support to stand united behind every detail of health care reform.

The newly opened Eastern span of the San Francisco-Oakland Bay Bridge
The newly opened Eastern span of the San Francisco-Oakland Bay Bridge

There is no precedent for implementing major health care reform in which major pieces have the potential to become major campaign issues every two years, nor does seem to be any certainty that the electorate will resolve the matter by favoring in the aggregate one party over the other.

There are other complexities to the implementation process. The legislation included roles for the 50 states, each of which could approach reform in different ways, so that there are at 51 governments (not counting local governments) involved in developing health policy.

Here the budgeting “reform” that requires estimation of federal government expenditures for the next ten years may be having a politically quixotic effect, and certainly has lent support to the argument that there is a moral obligation to future generations to reduce or eliminate the federal deficit.

The argument presented above is not meant to take a specific position, but to suggest that, in a conference that maximizes exchange of information and conversations between the conference participants, that there is much to talk about.

For the history of the National Conferences, see: The Background of the National Conferences on Primary Health Care Access.