Credit ACA for quality care 

"There is no limit to the amount of good you can do if you don't care who gets the credit," Ronald Reagan marveled, stealing a line from Harry Truman, who borrowed it from a British translator of Plato and Thucydides.

Here is a slight corollary: "... if you don't give credit to unpopular sources."

As you have guessed, I'm referring to the Patient Protection and Affordable Care Act of 2010 and the black president whose infamous name was attached to it five years ago as a way to defeat it.

The good news in the health care field has been coming weekly for three years, almost as often as the New York Times stories about some new perceived glitch caused by Obamacare, like the return this month to 2010 Medicaid payment rates for primary-care doctors. But Obamacare rarely gets credit for the good news.

New figures show that spending on health care in the United States for the last statistical year, 2013, grew at the lowest rate since the federal government began tracking it 55 years ago. Spending flattened at the depth of the recession in 2008, but it has remained nearly flat since the country climbed out of the recession about the time, in 2009, that the first house of Congress passed Obamacare. Health economists give varying degrees of credit to the Affordable Care Act, both the sweeping reforms that have insured 10 million people — some 300,000 in Arkansas — and the payment and care innovations that the law instigated.

In the Mike Beebe-John Brummett valedictory last month at the Second Presbyterian Church, Brummett asked the immensely popular governor to identify the greatest legacy of his eight years. Surely, Brummett said, it was passage of the "private option," the expansion of Medicaid that will soon reach 250,000 of Arkansas's lowest-earning grownups.

No, that wasn't it, the governor said.

Beebe may have figured that if credit was to be given it should go first to the people who wrote and passed Obamacare, which mandated adult Medicaid coverage before the Supreme Court said states could opt out of it. Beebe, the shrewdest politician of our time, knew right away, in 2010, that Democrats had lost the one-sided propaganda war over Obamacare and he never uttered one word for it — or against it, for that matter — even though Obamacare and the Obama stimulus saved his state health budget more than a billion dollars between 2010 and 2013.

Then Beebe also surely knew that, whatever his role in getting the private option passed, the credit in Arkansas should go first to the three nimble young Republican legislators who came up with the idea of substituting pure Obamacare — the subsidized plans on federal and state insurance exchanges — for cheap vanilla Medicaid and then twice getting enough Republicans to go along to pass the appropriations. His successor, Asa Hutchinson, is struggling with how to keep the private option going this winter by seeming to tweak it in some way that Obama might resent.

No, Beebe said, he figured his legacy would be the dramatic payment reforms he is making in Medicaid and beyond, which he said had sharply curtailed Medicaid and private spending growth while improving care. It was the so-called "patient-centered medical home." He hoped that Arkansas would show the country that getting away from the old fee-for-service model would drive a stake in the heart of skyrocketing health spending, which has driven the nation's fiscal crisis for 45 years.

Beebe's weekly column, which also bragged about the project, said the medical-home/bundled-payment system, which began in 2013, preceded the Affordable Care Act.

But it didn't. It was a big feature of Title III of the law, which proposed a number of demonstration projects that states and insurers were to undertake to improve the quality and efficiency of medical care. When the House version of the act adopted the models in 2009, they caught the eye of many in the health care field, including Andy Allison, Arkansas's Medicaid director at the time. He and Beebe talked about attacking Arkansas's mushrooming Medicaid share and this might be the way to do it. Arkansas, by the way, is not alone. Medical homes, supported by the Centers for Medicare and Medicaid under Obamacare, are burgeoning across the country. But you never mention Obamacare.

Not all the good news is, well, good. The University of Arkansas for Medical Sciences got word last week that its reimbursements may be trimmed owing to the very high rate that its patients get infections and are readmitted. Like other hospitals, it must take steps to improve its care. The stories didn't say but Obamacare dictates it.

While doing some frivolous research the other day, I came across an editorial I wrote for the old Arkansas Gazette Sept. 29, 1991. President George H.W. Bush had campaigned for president in 1988 partly on the promise that he would do something to end the health care crisis by finding a way to insure many more Americans, stop the bankrupting binge of health spending and improve medical outcomes. Ronald Reagan's right-wing think tank, the Heritage Foundation, had come up with a plan for him. It was what would become, in 2010, Obamacare: a mandate that people buy private insurance in government-sponsored exchanges, with federal help to the extent they needed it, along with incentives to improve care and reform costs. The editorial encouraged the president to jump on it. He dithered until he got a fresh term, which Bill Clinton denied him.

What I frankly doubted, though, was that those right-wingers who drew up his plan knew what they were talking about. It turns out they did.


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