Health Care Reform and Equity: Promise, Pitfalls, and Prescriptions

Kevin Fiscella

doi:10.1370/afm.1213

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Table 1.

Promise, Pitfalls, and Prescriptions for Improved Equity Under Health Reform

Health Reform Provision	Promise	Pitfall	Prescription
DHHS = Department of Health and Human Services; PBRN = practice-based research network.
Access (insurance and costs)
Expanded coverage	Coverage for up to 32 million uninsured	Need for robust primary care system	Revitalize primary care
		Remaining 23 million uninsured	Universal coverage
		Absence of “public option” undermines cost control for care for previously uninsured	Expansion of Medicare eligibility and other public options
Behavioral health parity	Reduced cost barriers	Does not address barriers related to stigma related to mental health care	Integrate behavioral health services into primary care
Elimination of co-payments for evidence-based preventive care	Reduce cost barriers	May accelerate trends toward cost shifting to patients for medical and behavioral care, worsening disparities	Restrict cost sharing based on percent family income
Revitalization of primary care including the safety net
Improved physician payments	Modest improvement in resources	Not sufficient to generate practice adaptive reserve for transformation	Major payment reform
Elimination in Medicare-Medicaid payment differences	Potential to minimize separate and unequal systems	Does not address gap between Medicare and private insurance payments.	Eliminate differences in payment by insurance type.
			Prohibit segregation of care based on payment type within health care systems that receive federal funds.
Bonus for work in short-age areas	Modest impact on physician maldistribution	Too small to have significant effect	Comprehensive strategy to primary care and workforce issues
National Health Care Work Force Commission	Potential to influence work force maldistribution	Depends on authority of commission to affect key issues	Address student selection, training, payments, and quality of practice in shortage areas
Improvement in federal load repayment	Improved recruitment to shortage areas	Does not address retention following fulfillment of commitment	Enhance quality of practice and payment
Collaborative Care Network	Improvement in care coordination for underserved	Need for vibrant primary care safety net to coordinate care	Strengthen adaptive reserve of safety net
Piloting of new care models	Spark innovation	Modest investments may not be sufficient	Support innovation in all practices
		Practice change is a continuous process	Greater funding for practice-based research for underserved
			Funding for primary care extension
State-operated health insurance exchanges	Opportunity to promote new care delivery models	Not all states will opt for innovation
Health information technology
Incentives for physicians and hospitals	Acceleration of diffusion nearing tipping point	Does not ensure improvement in quality	Support for quality improvement collaboratives that leverage health information technology
		Digital divide by practice and patient	Subsidies for safety-net practices and training and support for patients in use of health information technology
Payment model reform
Payment Advisory Board	Potential move from volume to value payment	Success dependent on members of board	Major changes in needed in quantity and type of financing for primary care
	Potential for changes in primary care payment
National Pilot Medicare Payment Program	Piloting of bundled payments	Relatively small change	Build in monitoring of effects on care for underserved patients
		Unknown impact of bundled payments on primary care
		Potential adverse impact on underserved
National quality strategy
Formal national quality improvement strategy	Potential to integrate multiple elements of health reform	Potential for neglect of the physician-patient relationship	Need to keep patient and relationships at fore
Reporting of performance by federal programs	Improved accountability for programs for underserved	Inadequate funding for implementation and PBRN research, particularly in safety-net practices	Improved funding for practice-based research, particularly safety-net practices
Monitoring disparities
Enhance collection of disparity data within health care	Improved detection of disparities	Assessing disparities does not assure they are addressed	Build in continuous loops between reporting, policy/intervention and follow-up
Analyze disparities trends	Identification of key disparities for targeted action	Monitoring alone is not sufficient	DHHS should hold federally sponsored programs accountable for progress in addressing disparities

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The Article in Brief

Health Care Reform and Equity: Promise, Pitfalls, and Prescriptions

Kevin Fiscella

Background The United States has made little progress toward greater equity in health care quality. This essay describes the potential promise, pitfalls, and prescriptions in recent health care reforms that could jump-start progress toward more equitable health care.

What This Study Found Recent reforms, particularly the Patient Protection and Affordable Care Act of 2010, offer a historic opportunity to make inroads in addressing health care disparities. Six key health care reform provisions are relevant to promoting equity: improved access, strengthening primary care, enhanced information technology, new payment models, a national quality strategy, and improved disparity monitoring.

Implications

Health care reforms offer an unprecedented opportunity to create a more equitable, patient-responsive health care system.
The creations of a more equitable and responsive health system will require effective implementation, improved alignment of resources with patient needs, and most importantly, revitalization of primary care. It may also depend in part on the ability of primary care clinicians to seize these opportunities and champion systems of care responsive to the needs of all patients.