The Patient Protection and Affordable Care Act turned 2 years old last week. This week, it faces a key test in the U.S. Supreme Court, which will hear oral arguments on challenges to its constitutionality.
President Barack Obama's health care reform law has a curious political history. Originally developed as a conservative proposal and embraced by Republican presidential front-runner Mitt Romney when he was governor of Massachusetts, it is now derided as "Obamacare" by GOP leaders determined to repeal it.
Many aspects of the law have yet to take effect, in part because of uncertainty caused by legal challenges. But, so far, it seems to have been good for people in Kentucky — a relatively poor state with some of the nation's highest rates of cancer, heart disease and diabetes and lowest rates of private health insurance coverage.
The law forbids insurance companies from discriminating against children with pre-existing conditions, Terry Brooks, executive director of Kentucky Youth Advocates, wrote in an op-ed piece. Adults also will get that protection in 2014.
Insurance companies also can no longer put lifetime caps on coverage benefits, Brooks noted, "so if a child beats leukemia at age 8, she will still be able to get the care she needs if she relapses at age 20."
Children have received preventive care and immunizations without their parents having to pay out-of pocket costs. Young adults have been able to stay on their parents' insurance until age 26 while they search for a job that includes health benefits — something that has been hard to find since the 2008 financial collapse.
Kentucky Voices for Health, a broad coalition of more than 250 groups in the state, notes that insurance companies must now cover more preventive care, such as mammograms and other cancer screenings, which results in better health and lower long-term health care costs.
Dr. Gilbert Friedell sees a lot of good potential in the law. The founding director of the University of Kentucky's Markey Cancer Center started the Friedell Committee for Health System Transformation in 2008 to help facilitate improvements in a fragmented and often dysfunctional health care system.
"My question for those who want repeal is, did you like what we had before?" Friedell said. "What do you want to do instead?"
Friedell said the biggest problem with the health care system is that it isn't a system at all, but a collection of silos and special interests whose business models are built around fee-for-service. That promotes cost escalation and pays too little attention to prevention, management of chronic conditions and coordination of a patient's care.
While the Affordable Care Act is far from perfect, Friedell said, it is an important step in the right direction for two important reasons: it provides money and government support for new ideas and methods for improving health care and lowering costs, and it encourages discussion for continuous improvement.
"The key to success will be the active participation of the public and accountability to the public," Friedell said. "At some point, somebody has to say, 'How is the system working? How does it benefit the public?' "
Too much of the health care debate has focused on costs rather than care and prevention, Friedell said. More investment in prevention would go a long way toward bringing down overall costs.
As an example, he cited figures showing that an increase in colonoscopy exams from 2001 to 2008 among Medicare patients reduced colon cancers and deaths among those seniors by 16 percent. "It shows what we can do," he said.
Friedell said he thinks the law is flexible enough to help states and communities tailor solutions to local needs as well as to address changes ahead. One such change is the need for more integrated care by a wider variety of professionals beyond physicians, such as nurses, nurse practitioners, physician assistants and even social workers.
That means more teamwork — something that wasn't happening nearly enough before the Affordable Care Act's passage two years ago.
"You might as well call it the Affordable Opportunity Act," Friedell said. "This gives us the opportunity to experiment, to look at new things that might work. Yes, money is a problem. If you focus on quality of care, there's no question in my mind that it will bring down costs. But it has to be given time."