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Implementing Health Care Reform

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Key Points from an Interview with HHS Secretary Kathleen Sebelius

Published by the New England Journal of Medicine

NEJM: You said recently "there is no turning back" from implementation of the Affordable Care Act (ACA), despite Republican resolve to kill the measure. The court suits that state attorneys general have joined notwithstanding, are most states on board with ACA's implementation?

Sebelius: I have been doing a lot of outreach to the nation's governors. States are really in the driver's seat of implementation unless they decide to step out of the way. Governors understand, whether it is creating an insurance exchange, setting up a high-risk pool, reviewing proposed increases in private insurance premiums, or any number of other opportunities, the federal government provides the backstop. People who say this is a federal takeover are simply misinformed. So in some states, the legal folks are pursuing court suits at the same time governors are moving forward to create a new insurance marketplace.

NEJM: Given the new political divide, how do you see 2011 unfolding in Washington in terms of implementation?

Sebelius: We have a law, and we will continue to implement it. With President Obama in the White House, efforts to repeal the ACA will not succeed. While the question of constitutionality will continue to travel through the courts, most people believe that the Commerce Clause covers the questions surrounding the coverage mandate.

NEJM: Since Massachusetts enacted health reform, the state has had its challenges in providing all its citizens with ready access to primary care. What message has the Obama administration taken from the primary care shortage, and how is it being implemented by the ACA?

Sebelius: Unfortunately, the shortage of primary care providers has been ignored for a decade or more, along with the fact that doctors whose practices are devoted to primary care are underpaid compared with specialists. So starting with the stimulus law and continuing in the ACA, there has been a significant focus on expanding the pipeline of primary care practitioners, gerontologists, and general surgeons. As a consequence of the stimulus money, an estimated 16,000 additional primary care providers will come through training pipelines over the next 5 years. We have also put more money into nurse training and education, and into mental health.

I believe that refocusing health interventions at an earlier stage, placing more focus on health and wellness strategies, would help reduce demand and promote population health. Recently, the Institute of Medicine released a report on the future of nursing and [nurses'] scopes of practice. The report includes a whole series of recommendations, but the key one says states should allow nurses to practice up to the skill level of their training. . . . We could put some incentives on the table to encourage that discussion.

NEJM | January 5, 2011 | Topics: Reform Implementation

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