Philanthropy and the ACA: Helping People Engage in Their Own Health and Health Care

 

While the Supreme Court’s decision on the Affordable Care Act (ACA) is being parsed across the country for its impact on individuals, institutions and states, for philanthropies large and small—both those focused on health care and those with other interests—there may be very different meanings. That’s why Philanthropy New York brought together five of us—an economist, a journalist, a consumer advocate, a government official and a policy leader—in mid-July for a discussion, led by a foundation leader and witnessed by both on-site and online audiences, about the ACA’s implications and the opportunities it opens up.

 

The richness of the presentations can’t be captured in this commentary, but all agreed that the Supreme Court’s ruling balanced ideological division and pragmatic compromise, affirming a vision of substantial but incremental health care reform—neither the single-payer aspirations of the left nor the competitive-market approach of the right. Simply stated, 30 million Americans stand to gain insurance coverage, while increased attention to care coordination, payment incentives, information technology and patient engagement aim to reduce the rate of health care cost growth—a fundamental challenge to economic security. Beyond those givens, discussants’ views were more varied, however.

 

For me, it seems clear that—unlike the emerging political consensus on health care reform of less than a decade ago—deep divisions today shape both presidential and congressional campaigns and presage an end-of-year congressional debate on taxing, spending and deficit issues, and perhaps on the ACA itself. The initial rejection of a largely federally funded Medicaid expansion by a number of governors marked the transition from a debate about program design to one on the goal, itself, of expanding insurance coverage among low-income Americans.

 

How, then, can philanthropy approach a subject of such great import within this environment of intense debate?

 

A starting point is one of the ACA’s most notable themes. By any measure, individual people, patients or consumers (the choice of term itself reflects different approaches) are likely to become more personally engaged in their health care and in maintaining their health status in the years ahead. This new and evolving topic calls for engagement, in turn, by a wide range of philanthropies. For those funders already working in the area of health policy, that may mean factoring in patient engagement to the change models they support—from a cost-sharing “skin in the game” approach on the right to a focus on social determinants of health on the left.

 

But there are also important roles for non-health care-centric philanthropies, beginning with clarifying the most basic elements of the law. Polls continue to reflect skepticism about the law overall, but strong support for many of its components. Politicized messages leave no room for nuance. So, simply telling the basics of the health care challenge and its various solutions—in other words, speaking to the questions of “What does this mean for me? What does this mean for all of us?”—offers real value.

 

Changes in how patients and health care providers interact are a big part of that conversation. The ACA encourages moving health care from a visit-based dyad of patient and doctor to more complex interactions with multiple professionals on a health care team. For clinicians, this also means thinking of groups of patients with differing needs, some with far more complicated problems than others. “From volume to value” is the new mantra, intended to control costs and improve quality of care through medical homes, accountable care organizations and other new models. Who will help individuals understand these changes?

 

Massive changes in information technology will require explanation, too. Our physician may have a laptop in the examining room. Lab results will be specific, not just “normal.” Increasingly, we will learn how our health status changes over time. We will be asked to consent to sharing our data with other providers and with researchers exploring the patterns from which new scientific discoveries will be derived. We will learn the balance between protection of our privacy and the life-saving potential of a readily accessible medical history if an emergency arises while away from our regular health care provider. The information revolution changes everything.

 

Almost any approach to health care reform will succeed in the long run only if we can also alter the deteriorating status of our population’s health. Today, there is a very real risk that our younger generations, and those to come, will have worse health status than their predecessors. Big-picture issues—the food economy, income disparities, social structures—deserve serious attention. But the most prevalent challenges—obesity, diabetes and hypertension—also require changes in personal behavior. A newly integrated health care system will be capable of providing needed intervention and support, but patients’ personal understanding of what can be changed, and how, is essential for effecting those changes.

 

Finally, people come with myriad backgrounds, opportunities, experiences and problems. Philanthropy has traditionally targeted unique communities, and that focus is still relevant today. Immigrants are not fully included in the ACA. Our diverse communities often face basic language barriers. Health insurance may be through Medicare, Medicaid or employer-based coverage, and some people will now experience the new rules and requirements of health insurance exchanges. We are still in just the early, if encouraging, stages of reducing traditional barriers between mental and physical health care. Numerous opportunities exist to address the long-term challenges of chronic illness. And we all die, whether discussion of that reality is accepted or not.

 

The Supreme Court’s decision on the ACA is important, as is the continuing societal debate. But the truly tectonic shift in health care is the newly defined responsibility and opportunity for people to understand, engage with and influence the trends of the future. We are moving from health care for us to health care with us. For philanthropy, that’s a golden opportunity.