The woman who delivered Obamacare

The US could learn a lot from the results achieved by the Irish health system, according to the woman appointed by president Barack Obama to lead the biggest healthcare reforms there in half a century.

Kathleen Sebelius served as US secretary for health from 2009 to 2014, during which time she implemented the Affordable Care Act, commonly known as ObamaCare, that extended health coverage to millions of previously uninsured Americans.

Sebelius, speaking before a visit to Dublin to pick up an honorary degree from the Royal College of Physicians in Ireland, describes health provision in the US before ObamaCare as “a lose-lose situation”.

“We were spending considerably more per capita on health than anywhere else – almost twice what you spend in Ireland – yet a significant proportion of the population had no coverage and the results were mediocre.”

Compared to the US, she points out, Ireland has higher life expectancy, lower levels of obesity and lowers rates for heart attack and stroke.

The former governor of Kansas was once touted as a possible running mate for Obama, and even as a presidential candidate in her own right. But that was before she ran into the massive challenge of reforming the US healthcare system.

Healthcare reform is a perennial of US politics and Hillary Clinton’s effort to change the system, during her husband Bill’s first term as president, was widely judged a failure. Things have gone somewhat better with the Affordable Care Act, but Sebelius didn’t always have an easy ride.

The rollout of ObamaCare endured a rocky start when technical difficulties stymied people’s efforts to sign up for weeks, and the law has struggled to win popular support. Sebelius admitted at the time the early days were a “debacle” and her relations with the president became difficult. But by the time she bowed out in 2014, about 7.5 million people had signed up and Obama sent Sebelius on her way with lavish praise.

She describes the results achieved by the programme as “pretty dramatic”. The number of Americans with medical coverage has grown by half and the health outcomes among the population have improved, she says. “Smoking rates are down, we’ve made a dent in obesity, especially among children, and there are fewer safety incidents and re-admissions.”

There are echoes of the debate in Ireland in her determination to shift the focus of health to preventative medicine, focusing on chronic diseases. As a result of the reforms of the past decade, she says, medical inflation in the US is at its lowest level in 60 years, and is barely greater than overall growth.

The key to change has lain in changing the role of government in health from a “passive payer” for services to an “active purchaser”. Payments are performance-related, based on outcomes: “doctors get paid for keeping patients healthy” rather than the number of procedures carried out or the amount of time people spend in hospital.

“It’s balancing act. There is the fear in health that we’re doing too many tests and procedures, while on the other side, consumers have a genuine fear of governments rationalising healthcare.”

Ireland could learn from America’s recent experience of healthcare reform in a number of areas, she suggests. Over the past 10 years, the US has created a fully digital healthcare system, so that patient’s information is stored electronically and can be shared between different providers. The ObamaCare reforms couldn’t have happened without this shift, Sebelius says.

An intense focus on smoking and obesity has also showed results. In the US, smoking rates have halved, down to 13 per cent, far lower than Ireland. Obesity is proving a harder nut to crack but a wide range of measures have been implemented, from mandatory calorie counting to exercise programmes, biking facilities and measures to tackle “food deserts” where access to fresh fruit and vegetables is lacking.

Sebelius was a highly popular governor of Kansas before her stint in the Obama administration, during which she set up a state drug importation programme to help constituents afford prescription medicines. Incredibly, given our views on the cost of drugs here, Ireland was one of the countries from which this buyers’ club imported medicines.

“We needed – and we still need – more attention paid to the costs of drugs. Many of the old folk in Kansas were struggling to buy the prescription medicines they need.”

The venture was shut down by the US Food and Drugs Administration after 18 months but she says balancing the cost of “dazzling” new drugs against their availability is still one of the most significant issues faced by all health systems.

The US is effectively subsidising research and development for the rest of the world, with consumers in US paying the cost, she claims. “There is a lot of anger about this.”

An Irish-American – her maiden name is Gilligan and her father is a former governor of Ohio – Sebelius is a committed Catholic who believes abortion is a sin but she is also staunchly pro-choice.

As in Ireland, abortion is a controversial issue in the US. Her stance has prompted some Catholic bishops to warn her not to take communion.

One of her donors, a doctor who carried out late-term abortions, was killed in 2009 by an anti-abortion activist.

Sebelius says as an elected official her duty is to follow the laws of the land rather than impose her religious beliefs on others.

Sebelius says the Church has been quicker to “target” women leaders who do not follow their line while men who say the same thing are not “called out”.

She faults opponents on the issue for being quick to express outrage about attempts in other countries to impose religious doctrine such as Sharia law while not having any problem about proposing a similar approach in the US.