The University of Pennsylvania School of Nursing operates a Program for All-Inclusive Care of Elders, or PACE. The PACE effort there, for which the university assumes all financial risk, is called LIFE, Living Independently for Elders. Consider one example of the potential power of this Medicare & Medicaid Services model of care, which provides comprehensive services that enable most participants to receive care at home rather than in a nursing facility:
A patient in the LIFE program had significant respiratory problems that worsened one summer during a particularly severe period of high heat and humidity. When the patient was seen repeatedly in the emergency room and hospitalized for acute respiratory and cardiovascular distress, the interprofessional LIFE team decided that the patient’s health would be improved and the program’s costs reduced if LIFE bought the patient an air conditioner. They did, and it worked.
This simple intervention reveals the potential effect of PACE services and the PACE capitated payment model. Like other PACE efforts, LIFE improves older adults’ quality of life and function, reduces institutionalization rates, and lowers health care costs. Under the Affordable Care Act (ACA), PACE initiatives are to be expanded. But if elected, will Mitt Romney repeal this part of the law?
The ways in which a President Romney might repeal or fail to implement the ACA are convoluted, as Lawrence Gostin recently pointed out on this JAMA Forum blog. A total repeal is unlikely unless the Republicans are able to take control of 60 seats in the Senate. If the entire law is unlikely to be repealed, what parts of the law would Romney retain or rewrite into new legislation?
A great deal of attention has been paid to the ACA’s insurance reforms, the individual mandate, the extension of coverage under Medicaid, and state health exchanges. But Romney hasn’t discussed other aspects of the law, or he’s discussed them in terms that most voters won’t understand. An example of the latter: the Pulitzer Prize–winning fact-checking site PolitiFact.com pointed out that when Romney says he would support the ACA feature that prevents insurers from discriminating against individuals with preexisting conditions, he adds the qualifier, “who maintain continuous coverage.” This qualifier will permit insurers to deny coverage for preexisting conditions to people who have lost their insurance for a period of time.
More troubling is Romney’s lack of detail about other aspects of the ACA that he would seek to repeal, reconcile, or deregulate out of existence. Here are just 4 aspects of the law that have the potential for truly transforming how and what health care is delivered:
1. Transitional Care Projects
Transitional care helps patients and family caregivers better manage their posthospitalization care and self-care and improve their support from primary care providers. The transitional care demonstration projects provide the impetus for lowering hospital readmission rates, improving chronic care management and health outcomes, and saving an estimated $5000 or more per Medicare beneficiary. Transitional care has been repeatedly demonstrated to improve outcomes and lower costs by Mary Naylor, PhD, RN; Eric Coleman, MD; and others. Will these projects and others continue if Romney is elected as president?
2. Home Visitation Programs
Home visitation programs for high-risk mothers and infants is based on the Nurse-Family Partnership (NFP) started by David Olds, PhD, and Harriet Kitzman, PhD, RN. Their research has shown short- and long-term benefits for both mothers and children, including better pregnancy outcomes (a 79% reduction in preterm delivery for women who smoke and 35% fewer hypertensive disorders of pregnancy, for instance), reductions in high-risk and subsequent pregnancies, fewer injuries and poisonings among children, fewer emergency room visits, and reduced child abuse. And all of this means a return on investment of an estimated $5.70 for every dollar invested in the NFP. Will Romney eliminate these visitation programs because they often entail government investments?
3. Expansion of Primary Care Workforce
The ACA provides funding to expand the National Health Service Corps and professional and postgraduate training programs for primary care clinicians. Expansion of the primary care workforce assumes that increasing the number of people covered by private or public insurance will increase demand for primary care, as happened in Massachusetts. Romney says he wants to reduce the number of the uninsured. But how would he do that unless he ensured an adequate primary care workforce?
4. Accountable Care Organizations
Accountable care organization (ACO) demonstration projects are underway and more will be approved for funding soon by the Obama administration. The current ACOs are networks of health care organizations, physicians, and others aligned to provide comprehensive care to a minimum of 5000 Medicare beneficiaries. These ACO experiments hold the promise of pushing the realignment of health care organizations and services into a comprehensive system of care that can incentivize savings under the current fee-for-service model (and, one hopes, eventually operate under capitated or bundled payment models) while meeting quality benchmarks. What will Romney do with these demonstration projects?
I contacted the Romney campaign to ask for more details on his position on the ACA but got no response. Most health care professionals I know agree that we must transform health care if we are to meet what former Center for Medicare & Medicaid Services administrator Donald Berwick, MD, referred to as the “triple aim”: improve the public’s health, increase health care quality, and lower costs. The innovative example from the LIFE program—that air conditioner for a patient with respiratory problems—shows that we can achieve this.
The ACA is not a panacea, but it is a beginning. We shouldn’t waste time overhauling it. Let’s refine it and get on with achieving these aims.
About the author: Diana Mason, PhD, RN, is the Rudin Professor of Nursing and Co-Director of the Center for Health, Media, and Policy at the Hunter College, City University of New York, and President-elect of the American Academy of Nursing.
About The JAMA Forum: To provide ongoing coverage throughout this election year, JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide insight about the political aspects of health care. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.