“Well, at least it’s good to see a doctor who is excited about health care reform,” my sister-in-law’s aunt said to me at Thanksgiving dinner. “For the insurance companies, it just looks like more regulations.” As it turns out, she works as a lawyer for a health insurance company.
It is often said that one should avoid discussing religion and politics at family gatherings, advice that I typically take to heart. But in California, where I work at a community health center, health care reform is building steam. The topic has become unavoidable.
With the passage of the California “Bridge to Reform” Medicaid Waiver on Nov. 2, 2010, the federal government granted California a $10 billion health care package that will expand access to Medicaid for adults, provide more funding to safety-net hospitals, and streamline care for seniors and chronically ill children. It will increase the capacity for demonstration projects—innovative programs desi
gned to optimize comprehensive care. Financial gains from improved efficiency will be reinvested in the health care system. More recently, President Barack Obama signaled on Feb. 28 that he supported even greater flexibility for states, offering to waive requirements of the 2010 health care law for those that find other ways to expand coverage and control costs.
By using federal waivers to modify their Medicaid practices, many states gain the flexibility to better serve their local communities. Waivers allow these states to set aside the requirement to dispense Medicaid services according to standard federal operating practices. Although California has implemented waivers in the past, waivers claimed through the Bridge to Reform program are explicitly designed to usher in the new generation of health care.
Of course, the general elections Nov. 2 also resulted in a change in the congressional makeup—the Democrats lost their majority in the House of Representatives and lost influence in the Senate as well. This has spurred significant debate over the past weeks as to the fate of health care reform. Will it survive intact? Will it survive at all?
From my perspective, it feels as though federal programs have fueled a burst of creativity and energy that cannot be reversed. The transformation has come in two parts: the first is health information technology and the second is the Bridge to Reform.
I first felt the winds of change in spring of 2009. A new president continued a stimulus plan to bolster our failing economy. Almost immediately, money became available for the installation of health information technology. But the money wasn’t simply for purchasing electronic records systems. The rules demanded “meaningful use.” They paid not just for expanding access to technology, but also for ensuring it was fast and meaningful. They require not only that doctors use the system, but also that patients be able to review personal health information. They require doctors to share information with additional health services providers, like pharmacists and specialists.
My clinic will spend more than $1 million to implement an electronic records system, and every other community clinic in the Los Angeles coalition will also be working to implement their own systems. We live on the financial brink. There is no way that this would be possible without this direct government intervention.
When health care reform was signed into law Sept. 17, 2009, we felt it on the ground the next day. My husband, Carlos, who works as a pediatrician at UCLA, was seeing a child with a rare genetic metabolic syndrome. When Carlos first met this boy, the child was considered to be uninsurable because of his pre-existing condition. The boy’s family was petrified by the thought that their son would become ill and require hospitalization. But under the new law, in one day’s time, the child became insured.
Now, with the Bridge to Reform Medicaid Waiver, we are considering ways to accommodate the increased number of patients seeking primary care because of expanded access to health insurance. We also are embarking on collaborative projects to restructure Medicaid compensation to reward better health outcomes.
The flip side of improved access for some is a lack of access for those specifically left out—the undocumented. Those of us working in South LA have started to further categorize our patients into the “uninsureds”—those who will potentially become insured—and the “uninsurables”—those who have no hope for insurance coverage at all. Although the undocumented can now be lumped with the uninsured masses of LA, as the number of uninsured decrease because of provisions in health care reform, it may become increasingly difficult to advocate for those left behind.
In a previous issue of Focus (April 3, 2009), I wrote about Lakeesha, a 40-year-old woman who ultimately died of a delayed diagnosis of uterine cancer. She was caught in the catch-22 of California Medicaid. At that time, adults needed a documented diagnosis with proven disability to be eligible for the program. To receive the diagnosis, however, patients needed access to insurance. Lakeesha died because she did not receive a CT scan when she most needed one. If health care reform had come two years earlier, she might have lived.
Those of us working in health care in California are beyond the tipping point. Electronic records are the new reality, along with the improved quality control and enhanced communication they bring. Change isn’t coming. Change is here.
Ellen Rothman, HMS ’98, practices at a community health center in Los Angeles
The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions or Harvard University.
