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Unintended Consequences of Health Care Reform Assignment

The PPACA of 2010 fostered new provisions for health care and the structure of health care delivery. The individual mandate to obtain insurance is one provocative provision. While this provision attempts to increase access to health care, it raises questions on how the existing system could sustain the potentially large influx of newly insured individuals.

Another provision calls for new models of health care provider organizations to ensure delivery efficiency and continuity of care. In this week’s media presentation, Dr. Kathleen White discusses the accountable care organization, which comprises a group of providers coordinating care across a variety of institutional settings. Yet becoming an accountable care organization may present a number of challenges.

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This week’s Discussion builds on Week 1, continuing the examination of those societal and organizational contexts that influence health care reform. The unintended consequences of reform policy on the health care system are also considered.

To prepare for Unintended Consequences Of Health Care Reform Assignment:

  • Review      this week’s media presentation and the other Learning Resources focusing      on how reform may lead to improved quality, greater access, and reduced      cost of care. Also think about the unintended consequences that may arise      as a result.
  • Consider      the information presented about the individual mandate and accountable      care organizations. What are some questions or concerns you might have      regarding the individual mandate? What are the pros and cons associated      with becoming an accountable care organization?
  • With      posting instructions in mind, select either the individual mandate or      accountable care organizations as the focus of your Discussion this week.

Unintended Consequences Of Health Care Reform Assignment

The Robert Wood Johnson (RWJ) Health Policy Fellowships Program of the Institute of Medicine (IOM) conducted a workshop on August 22, 2000, on the subject of unintended consequences of health policy programs and policies. The purpose of the workshop was to gain a better understanding of why this phenomenon is a frequent and consequential byproduct of major health policy programs.

The workshop was based on a series of commissioned papers on the subject, written by current and former RWJ fellows. The papers, in the form of case studies, highlighted various examples of unintended consequences from the perspective of the authors’ expertise, special interest, or legislative involvement. The workshop brought together about 50 participants, most of them Washington-based policy experts working in government and leading health care organizations (see Appendixes A and C).

This workshop summary was prepared by an appointed rapporteur, Wendy B.Young, with the assistance of Marion Ein Lewin, director of the RWJ Health Policy Fellowships Program, and Kari McFarlan, deputy director. The summary was reviewed for accuracy in accordance with procedures approved by the National Research Council’s Report Review Committee guidelines.

Background and Overview

Since 1973, the IOM, with funding from the Robert Wood Johnson Foundation, has directed the RWJ Health Policy Fellowships Program, which is designed to develop the capacity of outstanding mid-career health care professionals in academic and community-based settings to assume leadership roles in health policy and management. Each year, six fellows are selected to participate in a 1-year program of orientation and full-time work experience in the nation’s capital. As part of their working assignment, fellows usually select work for a member of Congress or a congressional committee office where they play a senior role in developing health legislation and policy. Over the years the work of RWJ fellows on Capitol Hill has been praised for contributing valuable clinical and health sciences expertise to the legislative process (Breaux, 2000).

The workshop dialogue, moderated by Lynn Etheredge, a nationally respected health policy analyst, focused on nine case studies covering a broad range of policy issues (Appendix B contains descriptions of the case studies approved by each speaker.). The rich discussion yielded several observations regarding unintended consequences in general, and consequences of specific health policy programs in particular. The views expressed are solely the opinions of the authors and other participants.

A Long View: The Value of Historical Perspective

To set the stage for the discussion, Lynn Etheredge reviewed how valuable a historical perspective can be for revealing the outcomes of policies and for future policy planning. He reminded the group that, without conversations such as this, “the rich source of lessons from past health policy experiences tends to get lost and forgotten. This is unfortunate because so many of today’s priority health issues could be called ‘repeat encounters’. Whichever party is in the White House, whoever is in charge of Congress, and whoever the next round of RWJ fellows, they are inevitably going to face past issues and priorities in a different guise.”

…without conversations such as this, “the rich source of lessons from past health policy experiences tend[s] to get lost and forgotten…”

Etheredge cited Richard Neustadt and E.R. May’s book, Thinking in Time, as useful for understanding what brought us to where we are and the real-world problems facing public policy officials as they contemplate difficult choices:

“[Neustadt] argued that one of the most important things you can tell a new group who are going to deal with a public policy issue is the history of how we got to where we are. That is often overlooked but is very important because…it warns people that the status quo really does not have much standing except that it is a status quo. It wasn’t always the status quo. It didn’t get here because it was ‘right’ or someone planned that the world ought to be organized this way…. We got here in part because public policy officials made some choices in the past and sometimes where we are today is the result of successes, sometimes of unintended consequences, sometimes of both.”

The workshop… focused specifically on nine case studies covering a broad range of policy issues.

Etheredge challenged the authors and participants not only to create a record of the history of a particular policy development that will be useful to people who revisit the same kind of issue in the future but also to articulate general principles that can sensitize people to the value of discussions of how an understanding of the history of health policy in different areas can contribute to the future.

The case studies were grouped for discussion into three categories: Medicaid, Assessing Risks and Regulating Benefits, and Delivery System Restructuring. Each author briefly described how he or she became interested in the health policy issue and the major points of the case study. After a discussion of each case study, the dialogue shifted to general lessons for health policy that emerged from the nine case studies.

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