From the ‘Cliffs of Insanity’ to ‘As you wish’

Peter Long, Ph.D.

If you have ever seen the movie The Princess Bride, you know that it is an epic adventure that has a little bit of everything - revenge, miracles, and true love. You also know that the protagonists face a new challenge at seemingly every turn. Before scaling the Cliffs of Insanity, they sail through eel-infested waters. After wrestling Rodents of Unusual Size, they must escape the Pit of Despair. The hero of the film is an eternal optimist. He earns the love of the princess by meeting her every test and demand with a simple "As you wish," revealing a devotion that will carry him above and beyond any obstacle that comes his way. 

Those of us committed to access to health care for all feel a similar sense of devotion. Our dedication to achieving the type of healthcare system we know is possible should motivate us to overcome the inevitable challenges ahead. 

We’re now marking the third anniversary of health reform legislation; we have less than one year until full implementation of the Patient Protection and Affordable Care Act - the comprehensive federal law affecting every American that took more than seventy-five years and multiple failed attempts to achieve. Now that we have climbed the proverbial Cliffs of Insanity, there remain three immediate challenges for us to surmount: expanding coverage and maximizing enrollment in health insurance, ensuring adequate access to health care for the newly insured and remaining uninsured, and creating real value in the health care system.  

In California, an expected 4.6 million individuals will be covered by the Medi-Cal expansion and Covered California. Over the next nine months, important work must be done to make sure that many vulnerable Californians can benefit from the primary care and preventive visits made possible by the Medi-Cal expansion. The savings on out-of-pocket health care expenses and improvements in physical and mental health should be motivation for all of us to find a way to ensure the Medi-Cal expansion and enrollment efforts are successful in our state. 

Long-term, creative solutions for enrollment must bridge the divide between government and the health care system. UX2014, led by our colleagues at the California HealthCare Foundation, and including five national and three state foundations, provided an organized process to pool resources to develop an innovative online enrollment tool. More importantly, it created a platform to connect federal and state officials, community leaders, and representatives from the health system to share strategies on how to expand coverage. This unique public-private partnership can serve as a model for catalytic convening around enrollment and beyond. 

Once individuals and families have enrolled in coverage, they will rightfully expect access to a range of care options. With a dearth of primary care providers already a real challenge, particularly for those who participate in government-funded programs like Medicare and Medi-Cal, it is not feasible to produce more providers in time or to change the scope of practices sufficiently to meet the increase in demand. This seemingly intractable problem to expand access quickly provides us with the opportunity to fundamentally rethink the ways we deliver and pay for health care. 

To take full advantage of this opportunity, we must first commit to listening to patients and understanding what they need and expect from the health care system. We should focus on testing solutions that are based on the needs and preferences of patients themselves. In this way, foundations can play a transformational role in promoting patient-centered redesign. At a recent IOM workshop, diverse stakeholders came together to explore patient-engagement strategies and identify opportunities for advancing patient-centered care at multiple levels. 

The third and most difficult challenge we face is to increase value in our health care system. It is widely acknowledged that the US spends more on health care than any other nation and achieves worse outcomes across a number of dimensions. Yet, there is little consensus on the best approaches to produce better health outcomes, better patient experience, and lower costs. Data and thought are needed to support the policy and practice conversations that are occurring across the country. For example, the Commonwealth Fund’s High Performing Health System Commission recently released a report detailing how to cut $2 trillion from the current system while maintaining quality and improving outcomes.  The report reinforces that supporting local experimentation to improve quality and accessibility of care has the potential to influence and inform federal and state policies. There are no tricks or short-cuts to create greater value. It will be achieved by testing and evaluating a number of alternatives until we find some that work consistently. 

Much like the protagonists in The Princess Bride, those working for health care for all must be wise enough, nimble enough, and dedicated enough to survive these challenges and reach our final destination. The Patient Protection and Affordable Care Act is the single greatest expansion of the health care safety net since the passage of Medicaid and Medicare in 1965. That said, it is clearly not self-implementing. Today we stand closer than ever to achieving a sustainable American healthcare system that is the best in the world, guaranteeing high-quality, affordable care for everyone. In response to the clarion call for policymakers, stakeholders, and funders to work together to achieve this aim, the best answer we can hope for is “As you wish.” If these efforts are not successful, the overall promise of health reform will be diminished.


Photo © 1987, 2009 Twentieth Century Fox Film Corporation Photography © 1987, 2009 Act III Productions, LP All rights reserved.

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