Wednesday, January 17, 2018

Slogging through the Details

By Jacqueline Mitchell

Even though health-care reform is the law of the land, the tough part will be implementing it, medical school panel predicts

The national health-care reform bill Congress passed last month is a step in the right direction, but the devil will be in the details, according to a panel of experts moderated by Harris Berman, dean ad interim of the School of Medicine, during a Tufts forum on the new legislation on April 13.

Among the most sweeping changes in the federal bill are: all citizens will be required to obtain health-care coverage by 2014; employers must make affordable plans available to all workers; and insurance companies may not deny coverage on the basis of pre-existing conditions. (In 2006, Massachusetts enacted its own health-care reform, requiring nearly every resident to have a state-regulated minimum level of insurance.)

Amy Lischko, an assistant clinical professor of public health and community medicine, pointed to public health measures in the federal bill, such as funding for community health centers, incentives to participate in wellness programs and mandatory calorie labeling in chain restaurants nationwide. “This is a big deal,” concluded Lischko, the former Massachusetts commissioner of health-care finance and policy who was a key member of Gov. Mitt Romney’s team that wrote the Bay State’s health-care reform bill.

The federal bill also contains billions in funding for research and education, said Anthony Schlaff, an associate clinical professor of public health and community medicine who directs the school’s M.P.H. program. “Funding for preventative medicine research is up by 2,000 percent,” he notes. “It’s a tiny amount in the bill that will make a huge difference for public health.”

Passing the federal legislation was fraught with tremendous political divisiveness, but implementing it will be even tougher, said Jon Kingsdale, executive director of the Commonwealth Health Insurance Connector Authority, the independent body established under the Massachusetts health reform bill to promote coverage of the uninsured.

“This is going to be the toughest domestic policy to implement since the civil rights bill, so think Little Rock,” he said, referring to the racial tensions surrounding the integration of the Arkansas high schools in 1954.

However, he said, the Commonwealth’s bill “has been pretty darn good for Massachusetts,” extending coverage to 98.6 percent of the state’s citizens while adding $350 million—just 1 percent—to the overall budget. The federal legislation is “at least 15 times as complicated” as Massachusetts health-care reform, Kingsdale said, and he expects partisan politics to complicate the process of turning policy into practice.

All the panelists agreed that the new legislation stops short of containing the cost of medical care. “Cutting [insurance] rates does not equal cutting costs,” said Ellen Zane, president and CEO of Tufts Medical Center. Zane cited a survey of 400 MRIs her hospital performed on patients complaining of a headache; not one of the procedures altered the course of treatment.

Why did doctors perform the expensive tests? For one thing, the fee-for-service model that permeates the current health-care system encourages tests and procedures. Moreover, said Zane, patients felt entitled to them, and physicians are worried about malpractice suits. “It’s a consumer expectation that [health-care] plans are designed to reinforce,” she said. “It sets up doctors to have to fight with their patients. It sets people up for conflict. There is absolutely a consumer role here.”

Schlaff agreed. “We might need to pay physicians to see fewer patients and do a better job with each of them, more talking and counseling and fewer MRIs,” he said. “Reward that, and we might get somewhere.”

“[The bill] is a necessary step, but it doesn’t bend the cost curve,” said Paul Hattis, an assistant professor of public health and community medicine whose research focuses on health services management and policy. To do that would require a “fundamental shift away from the fee-for-service system. Until we do that, I don’t think there’s health-care reform in this country.”

In his concluding remarks, Berman urged all the medical professionals and students in the room to stay engaged in the health-care reform conversation. “We recognize that this system doesn’t work anymore, and we really need to keep thinking about ways to make it work,” he said. “Let’s not leave it to the politicians.”

Aviva Must, N87, N92, the Morton A. Madoff Professor and chair of the Department of Public Health and Community Medicine, which co-sponsored the event with the Dean’s Office, served as co-moderator.

Jacqueline Mitchell can be reached at

Posted April 21, 2010