Michael Dowling: The health reform debate is about conflicting ideologies — Leaders, don't let that deter your strategy

The debate over the future of health reform has been contentious, tumultuous and exhausting to keep up with. The inability of lawmakers to reach any level of agreement across the partisan divide means the ACA remains intact for the time being, but potential changes to the law, such as those that would undo Medicaid expansion and roll back coverage protections for the sick, could be calamitous to patients and public health.

Although our lawmakers have the potential to upend much of the insurance and health gains that the ACA helped achieve, we as hospital and health system leaders must remain vigilant in our commitment to provide care to those in need and preserve our mission to improve the health of our communities.

The most frustrating aspect of the conflict is that it is ideological, not practical. If the debate was immune from politics — which it never is — Congress could have a logical policy discussion. However, the debate is fundamentally about the role of the federal and state governments.

Often masked by headlines or purposeful obfuscation, it is clear that this administration is rethinking the relationship of the federal government and states. This New Federalism seeks to limit the role of Washington in not just healthcare, but in science, education, social services, law enforcement and government policy. New Federalism will drive budgetary priorities and it will continue to shape the debate on healthcare.

We should recognize there is no ill intent behind these philosophies. There is power in allowing market forces to self-correct some of the excess in healthcare delivery and consumption. Institutions and organizations breathe in and out continuously — centralizing for operational efficiency, decentralizing to get closer to the market and consumers' needs.

Yet devolving responsibility for healthcare to the local level, taken to the extreme, runs the risk of unleashing unintended consequences that would continue to whipsaw the American healthcare system and bring uncertainty and hardship to millions of Americans.

The federal government has an uneven track record in managing healthcare for Americans. It is important to debate its role. Yet, in the aftermath of the failed effort to repeal the ACA, it should be clear to all open-minded individuals that we need to move beyond the political gamesmanship in Washington to a substantive discussion on how we can modify healthcare policy in ways that will preserve access to those most in need and stabilize the insurance markets.

Regardless of whether the existing ACA will, as predicted by opponents, eventually crumble under its own weight, we need to act now to fix the underlying flaws of the law that are driving insurers out of the health exchanges and maintain provisions of the law that expanded access to approximately 22 million previously uninsured Americans.

It's easy to say you want to tear something down. It's more difficult to come up with a better replacement. Repeal and replace is the wrong approach: Congress should be fixing what was broken with the ACA while strengthening and maintaining what works. It should be a renovation job, not a demolition.

Now is the time to change course and focus on the aspects of the law that directly affect patients' health. Lawmakers must look at the current situation and ask how they can cover everybody. How can they expand access to care and how can they finance it? How can they bolster reimbursement to sustain the provider system? What are the core quality metrics for medical care? Hospitals are accountable for a plethora of quality metrics. Let's identify the 10 that are most important for strengthening patient care and focus on them. Recognizing that lifestyle choices largely dictate how healthy we are, what demands can we place on individuals to take more responsibility for their own behavior?  These questions are complicated and controversial, and, of course, are not new, but they are the ones that must be answered.

Financial peril at the provider level

If lawmakers fulfill any or all of their promises to alter the health law — freeze Medicaid expansion, rescind the mandate on coverage for essential health benefits or avoid covering those with preexisting conditions — healthcare providers still have an obligation and responsibility to care for anyone who comes through our doors, irrespective of whether they're insured.

Scrapping these provisions of the ACA would inevitably lead to much higher expenses for hospitals. While some providers are in the financial position to survive that kind of reduction in revenue, many others would be absolutely ruined. If federal funding for Medicaid expansion is cut, there would be more financial pressure on states, aid would be reduced and ultimately many hospitals could go under. If you don't protect the providers who are delivering the product, they can't care for the communities they serve. It's simple math.

Setting strategy in the face of uncertainty

At the same time, healthcare leaders must adjust their strategies now to become more efficient and lean, regardless of what ends up happening in Washington. First, assess core operations and see if there is anything that could be eliminated to reduce expenses. Next, ensure you are treating patients in the most-efficient and cost-effective setting.

We must also continue to grow our efforts around population health management and value-based care. Without the ACA it would certainly be more difficult, but continuing to focus on improving people's lifestyles and behaviors, strengthening our ties to the community and using data analytics to target at-risk populations will remain integral factors in producing positive patient outcomes. We cannot just retreat from these endeavors. On the contrary, we must invest in them even more.  

It's also imperative to maintain engagement among staff. When faced with uncertainty, many people have a tendency to pull away or let anxiety hinder their performance at work. Leaders have a responsibility to prevent and mitigate that as much as possibleby enhancing communicating with them.

We may not have all of the answers right now, but our staff needs to know that they are needed — by us, their colleagues and their patients.

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