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Healthcare reform in 2013: Enduring and universal challenges

Clarke, Sean P. PhD, RN, FAAN

doi: 10.1097/01.NUMA.0000427185.42306.14

The real challenges on the healthcare landscape aren't specific to the legislation—in fact,they're not even specific to the United States.

Sean P. Clarke is a Nursing Management editorial board member and the Susan E. French chairperson in Nursing Research and Innovative Practice at McGill University and its affiliated teaching hospitals in Montreal, Canada.

The author has disclosed that he has no financial relationships related to this article.

Healthcare leaders are still looking for a sense of what's to come in healthcare reform and for guidance about how to prepare for specific aspects of implementation. However, I'd venture that although there's a lot to know about and follow in the coming years, the lessons for managers and executives from the current wave of healthcare reform are actually broader. What isn't part of the legislation and court cases is as important to pay attention to as what's at the heart of the reforms. The real challenges on the healthcare landscape aren't specific to the legislation; in fact, they're probably not even specific to the United States.

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U.S. healthcare: Far from unique

Many looking from the outside at the U.S. healthcare system are struck by what they see as ample resources, exceptional leadership, and innovation in the health sciences, alongside a huge separation between the wealthy and poor in terms of healthcare access. Looking at their own countries, they often find the U.S. government's roles in ensuring healthcare access are less than straightforward and are struck by how much the notion of healthcare as market goods is accepted by Americans. Of course, seen in true international perspective, the truth is considerably more complicated. Extensive government involvement is actually a prominent feature of American healthcare. Likewise, there are extensive private, as well as for-profit, interests in every healthcare system in the world, and the United States is far from the only country in which significant responsibilities for health expenses fall on individuals and their families outside government subsidy or control.



Beyond the United States, citizens and even health professionals and managers have an idealized view of their own healthcare systems. Sometimes there's blindness to crumbling infrastructure, serious quality problems, and out-of-control costs. But even when shortcomings are acknowledged, in the end, deep commitment to their systems as reflecting national values blocks real discussion on the need for reform. Canada, for instance, has had numerous public hearings, commissions, and reports on its system. There are thousands of pages of testimony transcripts and recommitments to offering comprehensive and universal access. But insights and action plans to make the system sustainable aren't offered, despite obvious signs that affordability and quality of service are increasingly threatened.

Various experts have compiled lists of trends to track (such as the aging of populations and increasing chronic illness burden) and untapped opportunities to improve delivery and outcomes (such as information technology) in these reports, but skip over discussion of concrete ways to deal with healthcare system constraints. Furthermore, there hasn't been any real attempt to contend with the turbulence in societies and economies working their way through healthcare systems worldwide. Before the passage of the Affordable Care Act (ACA), a certain level of access to care was guaranteed in other countries' healthcare systems, but otherwise their unfinished business remains the same as in the United States.

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The policy dilemma—everywhere

Healthcare occupies an understandably huge place in the public consciousness in all countries, given its very personal nature as a service and its connections to life, death, and other major transitions in our lives. From a policy standpoint, it's a lightning rod for basic political opinions beyond healthcare: personal versus public responsibility, the impact of for-profit interests and the operation of free markets on the public good, and the advisability of government interventions in specific areas of private life. If the multiplicity of opinions among the public and lawmakers wasn't enough, healthcare is also a complex constellation of services that has spawned professions, industries, and organizations that have become hyperspecialized—carefully attuned to rewards and disincentives and deeply committed to either maintaining the status quo or seeing radical change in ways that will serve their interests.

Regardless of the country, healthcare reform is always, at best, a matter of “halfway” measures that please some, infuriate others, and rarely achieve all the goals targeted. Nonetheless, the complex solution to the problem of engineering uniform access to U.S. healthcare, given the dominance of employer-supported health insurance plans and that the ACA required so much political maneuvering to pass, makes for a fascinating story. Whether the political systems in various countries that generate solutions such as the ACA are any more or less dysfunctional than before is debatable, but most argue that it's increasingly difficult to keep political maneuvering quiet for long and that there are more places for voices of discontent to be expressed in the current Internet-driven media climate. There are also fewer incentives for elected politicians to make unpopular choices or advance policies that are complicated and involve subtleties or aren't appealing to large or powerful segments of the electorate.

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Basic point-of-care problems

The ACA was primarily, but not entirely, about the reform of health insurance coverage, although it has a number of other components, such as funding comparative effectiveness research to assist clinicians and patients in making better individualized choices in care. The challenge of coverage for the under- and uninsured was clearly a pressing one, and many agreed that national legislation of some type was necessary to address it. But healthcare systems are more than merely how the public handles the costs of service—they're also the services themselves. As so many have commented, the growing demands for healthcare, dissatisfaction with the quality or quantity of healthcare available, and difficulties controlling costs and finding the resources to pay for care are common to every healthcare system on the planet, especially in the face of changing economic conditions. The need for reform starts, but doesn't end, with promoting equitable access to care.

If it was so difficult to enact legislation around access to health insurance, can the delivery of healthcare be made safer, more effective, and more cost-effective in specific clinical settings through federal legislation? The real difficulty in formulating policy solutions with the potential to create enduring change in frontline service is the extensive interests in maintaining current arrangements that operate at both the national level and at the point-of-care. Usually, it's money at stake, but sometimes it's prestige, status, or even the psychological comfort of continuity with the past. It can be threatening to realize that one's role in the healthcare system and cherished approaches to providing service may be wasteful, ineffective, or excessively variable across patient groups or settings and, therefore, might no longer be viable. Not surprising, resistance to changes in organization or reimbursement of practice can be found at all levels of every profession and industry interest group.

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The path ahead: Delivering care differently

In many ways, the ACA is exactly like all the other pieces of healthcare reform around the world: good for some, bad for some, neutral for most. But that's the beginning of the story, not the end. With a dramatic (even if incomplete and temporary) response to the problem of financial access in place, can we reform our care locally to make it more responsive to the needs of patients, families, and societies and better control costs?

The constraints are clear—most agree that the funds devoted to healthcare can't continue to grow and the challenges of adjusting public and provider attitudes and reforming delivery methods are monumental. Although the public and segments of the healthcare community may have once thought that preferred practices and outcomes were obvious (access to all diagnostic and treatment technologies that might be available and “survival” in any amount at any cost), many different types of data show that in terms of ensuring quality of life and satisfaction with care, the patterns of service delivery need revisiting. The challenge is in teasing out what's appropriate, effective, and delivers the right combination of immediate and long-term benefits and inconveniences at sustainable costs to individuals and society out of the full roster of what providers can and would prefer to offer.

Approaches and venues in healthcare will change in the coming years and questions will continue to be asked about the right combination of healthcare workers to provide services that optimize quality and costs. Policy debates around what governments need to do to ensure equity and fairness in health services and how they should protect the public from unsafe care are likely to intensify. Even if future administrations reverse some or all of the features of the ACA, there's no fighting what policy experts call the “iron triangle:” Cost, quality, and access constrain each other in complicated ways. Even when it comes to a service as valued as healthcare, there are limits to what societies can and will pay for.

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Next steps for nurse execs

It's obviously important to track the political debates, court decisions, and industry responses and reactions to the implementation of reform. It's equally important to identify trends in the market for healthcare and how they might affect demand for services and the levels of reimbursement that can be expected. However, managers' core competencies and activities for the future are very clear regardless of the recent political developments in the United States: determining how services be can provided more efficiently and at a higher level of quality and guiding organizations through the necessary changes by ensuring that structures, processes, and outcomes are correctly aligned.

Will we do the right things on our own or will we wait to be forced? Coordination of care, cooperation with other providers, and tracking patient outcomes beyond the doors of individual clinics and hospitals were all logical moves—even before obvious financial incentives were created to encourage them. Can healthcare organizations become nimble and find and implement these innovations on their own? Can they identify traditions that are no longer sustainable yet hold on to the true “nonnegotiables” in healthcare?

The healthcare leader of the future will need to be creative, frugal, and flexible. Leaders will need to be talented motivators of healthcare workers who were socialized as members of “tribes” within their professions, specialties, and roles to help them become creative, flexible, and frugal too. Protected turf, unfettered professional liberties, disregard for costs, and limited accountability for outcomes will have to change. These aren't just imperatives for leaders in the United States and they certainly aren't specific to the post-ACA era. The end of the United States' status as the last major industrialized country without universal healthcare coverage for its residents will draw new attention to the challenges that the ACA didn't address and opens up new possibilities to examine urgent concerns about quality and costs faced by care delivery systems around the world.

© 2013 by Lippincott Williams & Wilkins, Inc.