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The Exchange

No Turning Back

Former Senate majority leader Tom Daschle and health policy expert Karen Davis dig into the Affordable Care Act’s effects on American health care and chart future priorities.

Interview by Karen Davis • Illustration by Yann Legendre

Despite a rocky start, the Affordable Care Act (ACA) has transformed access to health care in the U.S. Before Obamacare’s second enrollment period opens on November 15, former Senate majority leader Tom Daschle and the Bloomberg School’s Karen Davis met in Daschle’s Washington, D.C., office to consider ACA’s debut and its future challenges. Daschle is a senior policy adviser at the law firm DLA Piper and author of Critical: What We Can Do About the Health-Care Crisis (2009). Davis, PhD, is the Eugene and Mildred Lipitz Professor in the Department of Health Policy and Management and director of the Roger C. Lipitz Center for Integrated Health Care.

KD: How satisfied are you with the Affordable Care Act?

TD: I don’t think it was the best we could’ve gotten, but in politics you have to be pragmatic. You take it one step at a time. Social Security was passed in the 1930s, and it wasn’t anywhere near what it is today; the same with Medicare in 1965. So I see this as an installment, as an opportunity, really, to continue to improve health. It’s a very good beginning.

KD: What do you see as some of the early successes?

TD: Well, I think one of the most important things is one of the things that got the least attention. In January of this year … we eliminated all of the preexisting conditions issues. We eliminated the problems with regard to access to insurance. We eliminated the disparity between men and women, and what they have to pay. We gave young people the opportunity to access their parents’ plans. We did a number of things that really revolutionized insurance and health, and put greater emphasis on prevention.

KD: I think you’re right. I don’t think people remember that the insurance market was really deteriorating, with more and more people being denied coverage, or that came up for renewal and a big jump in their premiums if they had had health problems. And certainly as [a] major goal of reducing the numbers of uninsured, we’re making major strides.

TD: It’s pretty remarkable. We’ve expanded by more than 20 million people access to health insurance in various ways: Medicaid, young people signing up for their parents’ plans, people buying exchanges. We still, of course, have a long way to go. We’ve got over 25 million people that still need to get covered. But there’s no question we’re getting there.

...We should be concerned about the quality of health care in the United States. When we pay the most—now we pay almost $9,000 for every man, woman, and child in the country—and don’t even rank in the top 20 [countries] in most of the quality criteria, something is wrong, and we’ve got to address it.

KD: So do you think now, after four years, five years, there’s no turning back?

TD: I think there is absolutely no prospect for repeal. As a matter of fact, I think this is going to continue to grow in popularity.

KD: What are some of the improvements that you would like to see in the Affordable Care Act?

TD: We’ve got to put greater emphasis and move more quickly on payment reform. I’d like to set as a goal, as the [National Commission on Physician Payment Reform] recently announced, that by 2016 we’ve eliminated fee-for-service. That’s a pretty ambitious goal. I also think … we should be concerned about the quality of health care in the United States. When we pay the most—now we pay almost $9,000 for every man, woman and child in the country—and don’t even rank in the top 20 [countries] in most of the quality criteria, something is wrong, and we’ve got to address it.

KD: One of the challenges for Medicare going forward is to move from volume to value, not to pay for every test, every procedure, but really moving toward more of a bundle payment system. For example, take a hip replacement: paying a fixed fee that covers everything. Some call this “surgery with a warranty." [Laughter]

TD: My best analogy … is when you purchase a car you don’t purchase the steering wheel, the spark plugs, the trunk, the seats, the upholstery, with some exceptions. You have some choices, but by and large you buy the car. And that’s what I’m suggesting for health. You purchase the procedure, and that procedure entails all of the things that go into the pre-op, the op, the post-op and all of that.

KD: And certainly it’s not as if global payment is brand new. Organizations like Kaiser Permanente … have been around 50, 60, 70 years. What do you think are some of the barriers to [paying] a health system … a fixed amount of money per person … to deliver high-quality care and produce results?

TD: Well, without getting too provocative, I think that there are a lot of entities that benefit a lot from fee-for-service today. I mean, it’s a very lucrative concept for those that benefit from volume, and benefit [from a] lack of transparency. But I think the American people are becoming much more aware and much more demanding that they have greater transparency and greater opportunities to compare and contrast.


Progress on Health Care Costs

Davis and Daschle discuss the slowing rate of increase in U.S. health care costs.



Could Obamacare Be Repealed? 

The conversation continues with Daschle and Davis examining prospects for the repeal of Obamacare. They agree the likelihood is nil.


A Better Way to Pay

U.S. doctors spend $30 billion per year just dealing with insurance companies. There has to be a better, more rational way to pay for America’s health care bills. Daschle and Davis look at options.

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