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Learning from Past Healthcare Reform Efforts

February 27, 2013
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Can lessons learned from a Reagan-era law improve the Affordable Care Act?

A team of physicians at the University of Michigan Health System recently compared two major healthcare reform efforts to provide broad access to healthcare—the Affordable Care Act of 2010 and the Emercency Medical Treatment and Active Labor Act (EMTALA),  a 1986 law that  mandated universal access to emergency care. While neither law quite gets there, the physicians say, healthcare reform can still bring the nation closer to comprehensive, coordinated care for all.

That’s the view of the providers—a family physician, an emergency physician and a pediatrician/internist, which was published as a commentary in the Journal of the American Medical Association.  They assess the ability of both laws to meet the standard of providing access to basic healthcare to all people who live in the U.S., and conclude that both laws fall short of that goal. But they also note that lawmakers in Washington can apply lessons from the experience of the Reagan-era law to tweak the ACA so it comes closer to that goal.

I think the authors offer a very interesting perspective on how a law enacted 25 years ago can serve as a guide to improving the current healthcare reform initiative.

The authors note that the ACA doesn’t ensure access to preventative care for all or coordinate among all types of healthcare, and that 30 million Americans will still be without health insurance, even after the all of its provisions take effect.

One of the authors, Katherine Diaz Vickery, M.D., a health policy researcher who also sees patients at the U-M Ypsilanti Health Center, says that healthcare in this country is sometimes treated as a right and sometimes as a privilege. “When we compare EMTALA and the ACA, we see that while emergency care is treated as a right, primary care, it seems, is treated as a privilege,” she said in a statement. The authors note that while EMTALA focused on taking care of individuals in emergency situations, it did not address how to make all the people healthier overall.

Co-author Kori Sauser, M.D., an emergency medicine physician, says that the ACA does not go far enough in changing that perspective. Sauser notes that the ACA will allow millions of people to have access to primary care physicians and preventative health services. But she is not convinced that patients will choose primary care offices over the ED for their acute care. “A major missing piece in the ACA is in failing to determine how to connect emergency care with primary care resources in ways that meet patient s’ needs,” she noted.

EMTALA requires hospitals and providers to treat any patient who comes into an ED, and bars consideration of a patient’s ability to pay during emergency care. But in the ensuing years since it went into effect, patients who are unable to pay for care rely on emergency rooms, which has burdened hospitals and led to spending and potentially cost-saving primary and preventative care.

According to the authors, a major oversight of the ACA is that it doesn’t lay out a way to integrate the emergency and primary care worlds in a way that ensures access to care. At the same time, payments to hospitals for the uninsured are being decreased, despite estimates that 30 million will remain uninsured in 2020.

The authors conclude that “the ability of the U.S. healthcare system to satisfy the ethical obligation to ensure access to care—first codified in EMTALA—will be a core measuring stick for the success of the ACA and for any future reforms.” Both Vickery and Sauser note that the accountable care model may allow more patients to get coordinated care, but they hope that lawmakers will use the lessons from the earlier law to inform policymakers and health leaders to make potential changes to the ACA.