Q&A: Don Berwick Reflects on Healthcare Reform, Part II
HLM: So how do we reduce costs of end-of-life care if Washington won't go near it anymore?
DB: I think you'll see, or I hope, local communities, states, civil societies pick up this issue and say, "Oh no you won't. If you're too scared to discuss this in Washington, well we're not. We're going to make it real where we live."
The story now is in La Crosse, WI. Nobody is ordering anyone to do anything, like sign advance directives, but the whole community is now embracing the idea that they want control over their own lives. So if you live in La Crosse, the odds are you will have an advance directive, and people will know your wishes and honor them. This was first done by Gundersen Lutheran (Health System), and they did the right thing.
And there's The Conversation Project by Ellen Goodman, the Pulitzer Prize winner, where tens of thousands of people are getting on the website and learning how to have "the conversation" that gives you control of your own life. This is a problem that will be solved by society, more likely than the federal government.
HLM: Now that the Supreme Court has ruled and a presidential candidate's threat to overturn PPACA has passed. Is it full speed ahead to full implementation?
DB: I surely wish we could come together and lay aside our swords. But I think feelings are so raw and debates so angry, it is unlikely people will calm down suddenly and all come together. I suspect there will be legal challenges, but they won't prevail.
But the biggest risk now I think has to do with administrative needs to implement this law correctly, both at the state and federal level, and setting up the exchanges properly. Helping the uninsured become insured is a difficult set of tasks.
And if I were opposed to the ACA, which I am obviously not, and I wanted to continue to be destructive, I would simply starve the administration of resources so that information systems aren't modernized, potential beneficiaries aren't notified, so that people become confused. And I would slow down implementation of payment changes. I would do everything I could on the administrative and funding side to impede the law.
That's short-sighted, and doesn't serve the public well. But I'm a realist.
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