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Duke Med backs health care reform

Despite controversy surrounding the passage of the Affordable Care Act, leaders from the Duke University Health System have stood behind the legislation.

The Supreme Court decided the fate of the Patient Protection and Affordable Care Act, which has implemented a variety of changes to increase health care affordability to the general population, when it upheld all its provisions as constitutional, including a mandate that individuals purchase health insurance or pay a fine.

Representatives from Duke Medicine predicted three likely outcomes of the decision: the Supreme Court could uphold the ACA and all its provisions, uphold the ACA but not the mandate provision or rule against the entirety of the ACA. The mandate provision would require all Americans to have health insurance or incur a $95 penalty fee.

“With health care accounting for over 18 percent of the GDP, everyone should be concerned—if not marching in the streets—about costs,” said Nancy Short, former chair of the Accelerated Bachelor’s of Science in Nursing Program at the Duke University School of Nursing. “It is an imperfect piece of legislation…. That does not mean that Congress can’t amend or address these imperfections thoughtfully.”

Victor Dzau, chancellor for health affairs and president and CEO of Duke University Health System, said even if people disagree on specific aspects of the act, everyone agrees with the general principles behind the legislation.

“Every American—Republicans and Democrats—would agree that we want to provide better care at a more affordable cost and we want everybody to have access to care,” he said. “We should all work towards those main three goals—access, affordability and good quality.”

He noted before the ruling that the Supreme Court’s main challenge will be whether they should uphold the mandate, which would require everyone to have health insurance, are requirement that Dzau supports.

Although Americans are still witnessing the “evolving” effects of the act, patients have certainly benefited since the ACA’s passage, said Short, who is also a senior research fellow with the Health Inequalities Program at the Sanford School of Public Policy and an associate professor of nursing.

Short noted that the option for young adults to stay on their parents’ insurance plan until age 26 positively affects Duke students and the general population. Prior to the act, adults could only stay on their parents’ insurance until they were 18 or 21 if they were in school. As a result, adults ages 18 to 24 were widely known to be the least insured population in the United States, a statistic that has changed since the Act’s legislation, she added.

Patients also indirectly benefit from the increased funding provided for comparative effectiveness research, she said.

“The Act has stimulated a sea of change from the ‘gold standard’ of all research being randomized control trials to increased interest in comparative effectiveness research,” Short said. “[This] asks not only if the treatment… works, but also if the treatment… works better than what is already out there.”

The ACA was also successful in diminishing the ‘doughnut hole’—the period between coverage for prescription medication, said Dr. Robert Califf, vice chancellor for clinical and translational research and director of the Duke Translational Medicine Institute.

Short noted her support for the Act and mandate, adding that organized nursing—which includes the American Nurses Association, American Academy of Nursing and American Association of Colleges of Nursing—supports the ACA in its entirety.

Califf voiced his support for the act, but added that it is unknown if what is passed will be effectively implemented.

“The way laws get written is that there is a law, but a lot of what actually happens is dependent on how the government organization actually operates the law,” he said.

An ‘imperfect’ piece of legislation

Although representatives from DUHS have shown overwhelming support for all aspects of the ACA, they admit there are aspects of the legislation that need work.

The ACA is supposed to be coupled with reforms in order to bring down costs, Califf said, but these reforms are not guaranteed. It will also take a couple of years to see if the Act can be financially viable.

“Everything has to kick in together for this to work. Otherwise, with increased coverage, everything stays the same and it just causes a big deficit,” Califf said.

A classic quandary with health care is that Americans want both high quality and immediate health care without any tax increases, Short said, making it difficult to strike a balance. Still, she attributed the Act’s unclear financial model as a negative aspect of the legislation.

Short added that the “extreme” partisan nature of Congress is what birthed imperfections in the Act and will prevent changes from being made.

The main problem with the ACA is figuring out how to pay for it, Dzau said, but he believes providing insurance opportunities for everyone will be a good thing in the long run.

“It’s not easy to implement, but if we don’t take this situation or opportunity, we are not going to get what we want, which is better health care at an affordable cost,” he said.

Medical ramifications

The ruling will greatly impact the general population, Short said. Currently, insurers are unable to deny coverage to patients with pre-existing conditions, a provision that would go away if the Supreme Court were to rule against the mandate.

She added that if the Supreme Court were to rule against the entire act, several centers would be left unfunded, such as the Center for Medicare and Medicaid Innovation, and several states would not create health insurance exchanges.

“The Act has already permanently changed the conversation about health care delivery and health care,” Short said. “Patients are just beginning to see some benefits.”

Despite the Act’s patient focus, the ACA affects physicians as well, Califf said.

The biggest change in medical care is that more private practices are beginning to disappear, either making long-term contracts with health systems or being employed by them, he said. Although this trend began before the ACA, this pattern of disappearing private practices has continued with its passage.

Califf said it is unclear as to whether this is a good or bad change. In a private practice, a physician has his or her own equity, meaning it is run like a small business. On one hand, this requires a doctor to be highly innovative to run the best practice, but on the other hand, a physician may be incentivized to do things—such as run unnecessary tests—to make money.

“As an employee, you might be less incentivized to do things just to make money and… you have a better information system,” Califf said. “So there are the two sides of the coin.”

Correction: An earlier version of this article indicated that Nancy Short currently chaired the ABSN program. The Chronicle regrets the error.

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