Beyond Health Reform
Ken Thorpe, Robert W. Woodruff Professor and Chair of the Department of Health and Policy Management
Ken Thorpe leads faculty and students in shaping domestic and global policy
By Pam Auchmutey
In 1912, former President Theodore Roosevelt championed national health insurance in his unsuccessful bid to return to the White House. This year, a century after Roosevelt first proposed national health insurance, the U.S. Supreme Court upheld the Patient Protection and Affordable Care Act (ACA), signed into law by President Barack Obama in 2010.
Ken Thorpe has followed the arc of health care reform for more than three decades. During the 1990s, he advised the Clinton administration as U.S. deputy assistant secretary for health policy. Since 1999, he has grown Rollins’ programs in health policy and management as Robert W. Woodruff Professor and department chair, all the while serving as one of the nation’s go-to experts on ways to control health care spending. He also leads the Partnership to Fight Chronic Disease, a national coalition that has positioned obesity and related illnesses as a top health priority with a focus on prevention.
In the following Q&A, Thorpe shares his thoughts on the ACA and how Rollins faculty and students are shaping the health care reform landscape.
Q: During the Clinton administration, you advised the President and First Lady on health care reform. What are the differences between the Clinton and Obama plans?
A: There are more similarities than differences. They both tried to achieve universal coverage. The penalties for not enrolling were steeper in the Clinton plan than what the ACA requires. The biggest difference is that the Clinton plan built in serious cost containment. It included a set of goals in terms of the growth of private insurance premiums that mirrored the growth of the economy plus one percentage point. Essentially, there were some controls for premiums that grew faster than that. Basically, the plans were taxed at 100% of excess growth. So a very tight cost control system was built into the Clinton plan.
Q: Why was the Clinton plan unsuccessful?
A: Congress was not engaged from the beginning. The proposal was written in the White House from A to Z. No one obtained buy-in from the Congressional committees that were going to have to introduce and pass the legislation. The process and strategy derailed it, and the length of time that it took to put the plan together. Had it gone faster, the White House would have had a better chance of passing health care reform.
Q: The passage of the Affordable Care Act was a historic achievement. What is working well under the current law?
Ben Druss and David Howard
A: Several important provisions now in place are working well. For example, parents can cover their children up to age 26. That’s reduced the number of uninsured adults by 6.6 million people. So the ACA has had a major impact on increasing insurance coverage among young adults. It’s provided a range of benefits to seniors in the Medicare program, especially for people who have multiple chronic health conditions. It’s eliminated the so-called donut hole in the prescription drug program and provided better preventive benefits for those covered by Medicare. It’s provided tax credits to small businesses that offer insurance, making it more affordable for employers to offer coverage. It eliminates bans on pre-existing conditions among children. It eliminates the ability of insurance companies to discriminate based on health status—the community rating provision. Everybody will have access to health insurance even with a pre-existing condition—the guaranteed issue provision.
The major elements of the ACA are scheduled to take effect in 2014. When that happens, it will reduce the number of uninsured in the United States by 30 million people. Originally, 17 million of those people were to be covered through an expansion of state Medicaid programs. The Supreme Court decision now leaves it up to states to decide whether or not to expand their Medicaid programs. Regardless, the ACA will expand coverage to Americans who currently do not have health insurance.
Q: What isn’t working well under the ACA?
A: There’s nothing major. The biggest structural change requires putting together state insurance exchanges to provide an online marketplace where people can buy health insurance. Today, 11 states and the District of Columbia are moving ahead to do that. These exchanges must be up and running by 2013 for them to work by 2014 under the ACA. By default, the federal government will establish exchanges for states that do not set up their own. Past November, if Obama is re-elected, you’ll see a lot of activity because states will want to design and shape how these exchanges operate.
Q: In 2007, you established the Partnership to Fight Chronic Disease (PFCD). How did it come about?
A: It came in part from work I did in Vermont, where I helped the legislature put together a health care reform package that was passed. We began by focusing on affordability and the issues around chronic disease. We wanted to create a system that did three things: do a better job of averting disease, increase the detection of chronic disease, and more effectively manage patients with chronic disease. We learned that as you build that system up, it has the potential to control growth in spending. It was a place where we could start and build a broad coalition and apply that lesson nationally through PFCD.
Q: What has PFCD accomplished nationally?
A: Before the 2008 presidential election, our policy platform was adopted by the Democratic and Republican platforms. It formed a major part of the health care reform proposals by Obama, Clinton, and McCain. It’s completely changed the dialogue about where to look to save money in our health care system. Until a few years ago, most of the discussion focused on increasing insurance copays and deductibles instead of looking at the drivers behind increases in health care spending.
Q: Earlier this year, you wrote an article for Health Affairs that sets forth a strategy to reduce diabetes under the ACA. How would that work?
Kathleen Adams and Walter Burnett
A: Chronic diseases are responsible for seven out of 10 deaths each year and account for 75% of the nation’s health care spending. Flaws in the current health care system often lead to fragmented and expensive care for these conditions. The ACA includes several provisions that could be used to create a comprehensive approach to prevent chronic diseases such as diabetes. The strategy that we proposed has three parts: expanding the National Diabetes Prevention Program, a public/private partnership led by CDC, into more communities; introducing community health teams into the Medicare program; and using these teams to coordinate public health, prevention, and treatment. All would contribute to improving outcomes and lowering health care costs by promoting wellness and reducing hospital readmissions.
Q: Your previous research has shown that health care costs related to obesity will quadruple by 2018. What steps can be taken to prevent such a steep rise?
A: Funding community programs known to promote weight loss is one way. Our studies of the YMCA’s Diabetes Prevention Program show that participants age 60 and older lose weight and reduce their diabetes risk by up to 71%. Our estimates show that expanding the 16-week program nationally would cost $590 million—which includes training, data collection, and enrolling program participants—with funding from the National Diabetes Prevention Program and the Prevention and Public Health Fund, created by the ACA. This investment would save an estimated $2.3 billion in Medicare costs over the next 10 years.
Q: In 1999, you joined Emory to lead the Department of Health Policy and Management at Rollins. How has the department evolved since then?
A: It’s changed dramatically. We’ve tripled the number of faculty. We added a Master of Science in Public Health (MSPH), directed by Laurie Gaydos, to our two existing MPH programs in health services management and health policy. We added a new doctoral program in health services and research policy, led by Walter Burnett. We put into place an element of the Career MPH program that we continue to be involved with. With the growth in faculty, our research focus has broadened.
Q: What are the research strengths of the department?
A: One is the big picture side of health care reform. Several faculty focus on ways to control health care spending. Ron Goetzel works with employers to maintain worker productivity through chronic disease prevention and health promotion. David Howard studies various drug treatments and medical procedures to determine their effectiveness in reducing health care costs. Kathleen Adams is an expert on Medicaid and Children’s Health Insurance Programs, including how to slow the growth in spending while improving outcomes. Richard Saltman examines health policy reform and expenditures in other countries.
Another side is the economics of different diseases. We collaborate with schools and units throughout the Woodruff Health Sciences Center and Emory. Joe Lipscomb and other faculty work closely with the Winship Cancer Institute on cancer screening, cancer costs, and cancer epidemiology. Ned Becker and Steve Culler analyze different ways of treating heart attack and stroke and look at surgical interventions versus cardiology interventions to determine cost effectiveness. Benjamin Druss works to improve mental health care delivery and quality in communities. Kim Rask leads the Center for Health Outcomes and Quality, which bridges several disciplines to improve clinical outcomes.
Q: How does the rate of chronic disease in the United States compare with that of other countries?
A: There’s no question that other countries are facing an explosion of chronic illness. India, China, Southeast Asia, you name it. There are 80 million diabetics in India alone. Those are common interests, and we’re doing a lot of work in taking what we’ve found to be effective in prevention and delivery system reforms to reduce the growth of obesity, to reduce the growth of chronic disease—to keep people with four, five, six chronic conditions out of hospital emergency rooms and clinics. Those are all common features, unfortunately, that we’re finding between the United States, Eastern Europe, and Southeast Asia. It’s almost worldwide now.
Q: Currently, 40 of the 153 master’s students in the department come from other countries. What draws these students to Rollins?
A: We offer a strong foundation in health systems in general. A lot of international students focus on health management. They come to learn management skills, finance, and accounting—skills they can apply in their own countries. Historically, a lot of international students are physicians who want to gain experience in the administrative and management side of health care. This year, we have six King Abdullah Fellows here from Saudi Arabia. This group includes five physicians and a nurse who will help form the nucleus of a new CDC-like agency in their country.
Q: On the domestic side, what are students prepared to do when they graduate? Where do they work?
A: We try to give them a tool kit so they can hit the ground running in any industry they choose. We provide them with a strong foundation in the financing of health care and health care delivery and prevention. We keep them up to date on all the key issues. In my class, for example, we do a lot of work on the components of the ACA and some of the debates on entitlement reform. We provide a strong analytic foundation so they can do policy analysis effectively. And we want them to have core management and finance skills that are important anywhere they go. Basically, we want them to be as flexible as possible.
After our students graduate, they land jobs in the public and private sector. They work for federal agencies such as the Food and Drug Administration. They work for advocacy groups such as the Blue Cross and Blue Shield Association and consulting firms such as McKinsey and Company. They work for hospitals and hospital systems. And some work on Capitol Hill in Washington.
Q: Regardless of the outcome of the 2012 presidential election, where do you see health care reform five to 10 years down the road?
A: It will focus on the structural issues. It will change how we pay for Medicare by moving away from a fee-for-service system to a bundled payment system, which will ripple over into the private sector. It will build a delivery system that promotes integrated team-based care. And it will build a prevention structure that effectively reduces smoking rates, obesity rates, and other conditions.
Q: As a nation, have we turned a corner in terms of preventing disease and reducing health care costs?
A: No, not yet. We have a long way to go.