Now that the Obama Administration has secured a second term, health reform is a “go”.  Yet, gaps and questions remain, some of them potentially far more substantial than originally anticipated.  While the mandate on individuals to purchase health insurance has survived as a “tax,” states will have much more flexibility to opt in or out of expanded Medicaid coverage without losing all of their federal Medicaid funding.  And there is always the possibility of further cuts.

In the meantime, “wait and see” is no longer an option. With a “cup half full” vision, health reform can be viewed as a basic platform from which gaps can be filled.  How can we make the most of this platform?  How can we connect the people to the coverage offered by the exchanges and persuade people to buy it?  How can we connect the people who buy coverage to the care they will need? And how can we do so in a way that doesn’t break the bank?

Some answers to these questions are offered below.  I also invite you to join us on February 13-14, 2013 in Washington, D.C. at the Health Care Industry Access Initiative’s Access Summit where you can hear more from our experts in a variety of panel discussions about what will and won’t work to achieve access, and how health industry efforts are key to access and, in turn, the success of health reform.

If We Build The Exchanges, Will The Uninsured Come?

Much has been said about state delay and refusal to establish exchanges as a bad omen for health reform.  But even the original Medicaid program adopted in 1965 did not have all of the states stepping up at first, with Arizona trailing the pack until as late as 1982 when it finally adopted a Medicaid managed care system pursuant to a federal waiver.

Eighteen states (including DC) already have filed blueprints with the feds to establish exchanges, and another seven are currently planning federal/state partnership exchanges.  These states include Massachusetts, of course, but also California, where nearly 10 percent of the current uninsured population resides.  Other states may do so later, perhaps in response to a federally operated exchange, or because it ultimately becomes the will of the people.

Politics aside, the success (or failure) of the opt-in states will inform the decisions of the states now choosing to sit on the sidelines. Thus, states that decide to move forward to create exchanges can serve as “laboratories” for health care access strategies.

But, unlike the “field of dreams,” just because exchanges are built does not mean that people will come automatically to buy health insurance.  For some, the pain of the individual mandate penalty may simply not be severe enough to overcome the cost of health insurance.  We already know from previous experience, including SCHIP and the more recent ACA high-risk pool, that many who qualify for existing health care coverage programs don’t enroll in them for reasons including cost, lack of knowledge, the stigma of public assistance, and the simple lack of time.

How can we make the exchanges that are adopted robust marketplaces that promote the benefits and rewards of health coverage effectively?  How can we make it easy for people to demonstrate eligibility and then to choose and enroll in a health plan?  And once they are enrolled, how can we keep people in the system, without inadvertent drops in coverage from reenrollment glitches?

Experiments with in-store kiosks, on-line purchasing, collaborations between insurers and big box retailers, and similar steps to become consumer-friendly are showing promise for connecting people with coverage.  So, too, are technological advancements, including “apps,” that can connect younger, healthier people to insurance coverage.  As a result, companies in technology and retail are becoming health care companies in unprecedented numbers.

Success in health reform will depend on knowing the customer and tailoring products and approaches accordingly.  So what do we already know about the exchange-eligible population?  It is an ethnic, working population largely hailing from Latin American countries that lack a culture of health insurance. They are busy– often working multiple jobs without employer-sponsored health insurance – and have little time to choose among health plan options.  Mass mailings, which worked well for the Medicare Part D senior population, are not necessarily successful with this anticipated exchange-eligible population. Repeated personal contacts, especially by trusted individuals, do work.

If The Uninsured Obtain Coverage, Can They Obtain Access To Care?

Just because people sign up to buy insurance (or qualify for expanded Medicaid) does not mean that they will be able to access health care services. Finding a physician willing to take on new patients is a considerable challenge and will remain so given the work force shortage of qualified health professionals.  Thus, many newly insured will end up in hospital emergency departments for care that is more cost-effectively provided elsewhere.

How do we connect the newly covered population to health care services?  Innovative care models are relying more on non-physicians — indeed, non-health professionals — to reach out to patients to ensure patient compliance with drug regimens and check on patient health status without the necessity of an office visit.  Other models are making health care services more convenient and “user-friendly” — moving beyond “bankers’ hours” care in professional buildings to after-hours care and convenient clinics located where people work and shop. Current experiments with reconfigured old solutions like physician house calls also are showing promise, as are technology-based solutions that can triage patient problems without costly emergency department visits.

How Can Cost Transparency And Wellness Contribute To Access?

Of course, the “elephant in the room” continues to be cost — not only the cost of purchasing health insurance, but the ongoing out-of-pocket costs associated with obtaining health care services. While there was good news last year that health insurance cost increases had moderated, recent reports are showing an uptick in rates.  And as the Massachusetts experience has shown, health reform alone won’t keep people from experiencing financial problems, including bankruptcies, from large, out-of-pocket health care costs.  Health plans available on the exchanges will likely have similarly large coinsurance and deductible consumer obligations as well, making consumer cost a key access issue despite health reform.

How do we take the mystery out of health care pricing so people will know what they are paying up front, not after the service is furnished?  Certainly people will be more likely to get the care they need when they know in advance what it costs. Web sites are beginning to emerge which provide comparative information on health care services, allowing consumers and employers to shop for them.  Insurers and employers both are seeking to provide cost-effective care networks through medical tourism and contracts with centers of excellence.

Ultimately, the question is how do we keep people from needing costly health care services in the first place?  After all, being healthy is not just about obtaining health care services, and healthy people won’t need expensive health care services.  Wellness programs (diet, exercise, smoking cessation and the like) are important, but let’s not overlook public health solutions that have proven effective in third world nations and can work here, too.

Typically focused on a broad perspective well beyond treatment by health professionals and facilities, public health solutions look instead to the larger issue of people’s living environments — the air they breathe, the water they drink — and how those environments can contribute to disease.  Emergency room visits and hospital admissions for asthma complications, for instance, can be radically reduced when mold is removed from housing. Infant deaths from SIDS can be largely avoided when portable cribs are made available to transient families. New organizations are taking on the task of connecting patients to social services that can address the source of their health care problems.

The Health Care Industry Access Initiative Summit.

The next few years pose an unprecedented opportunity for the health care industry to both “do good” and “do well.”  The challenge will be to embrace these fresh ideas for enhancing health care access and scale them to reach the larger population of health care consumers, and to collaborate across the health care industry to do business in a new way that is patient-focused, customer friendly and cost effective.

The Access Summit will focus on these challenges on February 13-14, 2013 in Washington, DC. For more information about the Summit, click here.

The Health Care Industry Access Initiative is a nonprofit, tax-exempt organization dedicated to promoting collaboration across the health care industry to improve access to health care coverage and services in the U.S.  We invite you to join us for a day of strategic thinking in keynote and panel discussions designed to develop and promote best practices for accomplishing health care access and, in turn, success in health reform.  This is an opportunity for senior health care executives to make a difference!  We will record key portions of the Access Summit and publish the results.

We look forward to seeing you!