Medical Directors Forum

With ‘Repeal and Replace,’ The Triple Aim Needed More Than Ever


Eneida O. Roldan, MD, MPH, MBA
CEO, Florida International University Healthcare Network

In May 2008, Donald Berwick and his colleagues published their now-famous article in Health Affairs about the Triple Aim. The United States will not achieve high-value health care, they wrote, unless it pursues three interconnected goals: improve the individual experience of care, improve the health of populations, and reduce the per capita costs of care.

The Triple Aim hit a nerve with medical directors and health care managers of all kinds. Thinking in threes is always a good idea when making a new proposal or analyzing a problem. But beyond presentation, the Triple Aim was also a concise way of summarizing the disparate issues that anyone trying to manage the delivery and cost of health care must deal with. And, importantly, it addressed them at the population level without losing sight of the individual patient.

Six months after the Triple Aim article was published, Barack Obama was elected president. And about two years later, on March 23, 2010, he signed the ACA into law.

Eneida O. Roldan, MD, MPH, MBA

Eneida O. Roldan, MD, MPH, MBA

Parts of the law were inspired by the Triple Aim, but the ACA was mainly about expanding health care insurance through the exchanges and Medicaid expansion. The law succeeded in lowering the uninsured rate to an all-time low but fell well short of the goal of universal coverage. Incentives to buy coverage weren’t strong enough. As a result, risk was not diluted enough and selling plans on the ACA exchanges was not a cost-effective proposition for insurers. Because of the 2012 Supreme Court decision on the ACA, the law did not require states to expand their Medicaid programs. State discretion over Medicaid expansion left many Americans uninsured, and they continue to seek care at overburdended safety net hospitals.

Now, of course, we are hearing a lot about repeal and replace. Early indications from the White House and HHS Secretary Tom Price are that health savings accounts (HSAs) will be an important part of any replacement plan. HSAs are seen as a way of bringing market discipline and individual autonomy to the health care system because the accounts put an individual’s money at stake. Allowing health insurance to be sold across state lines and turning Medicaid into a block grant program also seem to be figuring prominently into Republican plans.

So, where are we now? As of this writing, in the dark, mainly. There is no timeline, no legislation.

But regardless of what emerges from repeal and replace, it must take into account patient preferences and behavior if it is to be successful. A customer/patient educational platform will be necessary to make changes that will be sustainable, reproducible, and supportive of true patient autonomy. The patient experience is one of the three legs of the Triple Aim. With the unraveling of the ACA, we should rely on the Triple Aim as the guidepost for designing a health care system that Americans need and deserve.

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