Table 1.

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

Health Reform ProvisionPromisePitfallPrescription
DHHS = Department of Health and Human Services; PBRN = practice-based research network.
Access (insurance and costs)
Expanded coverageCoverage for up to 32 million uninsuredNeed for robust primary care systemRevitalize primary care
Remaining 23 million uninsuredUniversal coverage
Absence of “public option” undermines cost control for care for previously uninsuredExpansion of Medicare eligibility and other public options
Behavioral health parityReduced cost barriersDoes not address barriers related to stigma related to mental health careIntegrate behavioral health services into primary care
Elimination of co-payments for evidence-based preventive careReduce cost barriersMay accelerate trends toward cost shifting to patients for medical and behavioral care, worsening disparitiesRestrict cost sharing based on percent family income
Revitalization of primary care including the safety net
Improved physician paymentsModest improvement in resourcesNot sufficient to generate practice adaptive reserve for transformationMajor payment reform
Elimination in Medicare-Medicaid payment differencesPotential to minimize separate and unequal systemsDoes 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 areasModest impact on physician maldistributionToo small to have significant effectComprehensive strategy to primary care and workforce issues
National Health Care Work Force CommissionPotential to influence work force maldistributionDepends on authority of commission to affect key issuesAddress student selection, training, payments, and quality of practice in shortage areas
Improvement in federal load repaymentImproved recruitment to shortage areasDoes not address retention following fulfillment of commitmentEnhance quality of practice and payment
Collaborative Care NetworkImprovement in care coordination for underservedNeed for vibrant primary care safety net to coordinate careStrengthen adaptive reserve of safety net
Piloting of new care modelsSpark innovationModest investments may not be sufficientSupport innovation in all practices
Practice change is a continuous processGreater funding for practice-based research for underserved
Funding for primary care extension
State-operated health insurance exchangesOpportunity to promote new care delivery modelsNot all states will opt for innovation
Health information technology
Incentives for physicians and hospitalsAcceleration of diffusion nearing tipping pointDoes not ensure improvement in qualitySupport for quality improvement collaboratives that leverage health information technology
Digital divide by practice and patientSubsidies for safety-net practices and training and support for patients in use of health information technology
Payment model reform
Payment Advisory BoardPotential move from volume to value paymentSuccess dependent on members of boardMajor changes in needed in quantity and type of financing for primary care
Potential for changes in primary care payment
National Pilot Medicare Payment ProgramPiloting of bundled paymentsRelatively small changeBuild 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 strategyPotential to integrate multiple elements of health reformPotential for neglect of the physician-patient relationshipNeed to keep patient and relationships at fore
Reporting of performance by federal programsImproved accountability for programs for underservedInadequate funding for implementation and PBRN research, particularly in safety-net practicesImproved funding for practice-based research, particularly safety-net practices
Monitoring disparities
Enhance collection of disparity data within health careImproved detection of disparitiesAssessing disparities does not assure they are addressedBuild in continuous loops between reporting, policy/intervention and follow-up
Analyze disparities trendsIdentification of key disparities for targeted actionMonitoring alone is not sufficientDHHS should hold federally sponsored programs accountable for progress in addressing disparities