Back in April when we were not absolutely sure who the nominees for president would be. Michael Cohen wrote “Obamacare: an unheralded success” in the Boston Globe. He  commented then that healthcare was not getting much discussion by Republicans beyond a flat out assurance that the ACA would be abandoned on the first day of a Republican presidency. Over in the Democratic Primary Bernie and Hillary were in a confusing debate about the merits of single payer versus continued efforts to improve the ACA. Cohen’s point was that the health care discussion was a major part of the discussion about “inequality”. His corollary to this observation was that few people really understood or appreciated what had been accomplished by the ACA:

Few issues have dominated this year’s presidential campaign more than income inequality. For Bernie Sanders it is the core message in his pursuit of the Democratic nomination. And it is one that has been picked up by Hillary Clinton, who talks of reducing barriers for all Americans.

But not enough attention is being devoted to the government program that is playing an increasingly critical role in reducing inequality: the Affordable Care Act.

If anything, Obamacare has been the red-headed stepchild of this campaign. For Sanders, a single-payer advocate, it doesn’t go nearly far enough. On the Republican side, hardly a day goes by without a presidential candidate vowing to repeal the bill, sometimes on his first day in office.

The remainder of his article was an attempt to enlighten or remind readers of the remarkable accomplishments of the ACA. I loved what he continued to emphasize.

studies…indicate that Obamacare is making a life-changing difference for actual Americans. According to an analysis by The New York Times, the first full year of the ACA “brought historic increases in coverage for low-wage workers.” Immigrants saw the sharpest rise in coverage. In particular, a third of those who gained insurance are Hispanic — and two-thirds are minorities. The numbers would be higher but or the fact that blacks disproportionately live in red states that have rejected Medicaid expansion.

These are Americans who previously could not afford coverage or were restricted from purchasing even inadequate individual insurance plans because of preexisting conditions. Now they don’t have to put off seeing doctors and can have illnesses treated when they’re sick, not when they can afford it. …

Within that concise statement lies the explanation for the silence on the Republican side. In states they control healthcare inequality is as bad as it ever was for minority populations and the most obvious beneficiaries of the law often don’t vote. If they do vote, they are more likely to pull the lever for a Democratic candidate. One of the confusing realities of this election is why poor white voters, most significantly men without a college education and their families who are also potentially huge beneficiaries of the ACA, are frequently aligned against their own best interest. J.D. Vance, himself a product of this demographic, gives a great explanation for this reality in his new book, Hillbilly Elegy. I recommend the book, especially chapter nine, to anyone who seeks to understand the contradictory thinking of many who favor Trump when a rational analysis would suggest that they would have more to gain as individuals from a Clinton victory. I bought both the hardcopy and the audiobook which is beautifully read by Vance in his mostly Midwestern, slightly Southern Appalachian voice.

Paul Krugman, articulates how the law has already improved both the physical and the fiscal health of so many Americans. With all the benefits the real question is why is the law such a source of contempt and why is there not bipartisan enthusiasm to fix the flaws that are no apparent with ACA 2.0? There is a lot to read if you just type “how can we improve the ACA?” into your browser.

Politicians who oppose the law love to allege that the President “lied” six years ago when he told Americans that if they liked their healthcare coverage they could keep it. The assertion that the President “lied” is itself a stretch of the truth motivated by resistance to the intent of the law. What I heard him say was that if your current plan qualified under the mandated benefits of the new law, then you could keep it. Those Americans who could not continue their plan were in plans that were discontinued because of non complying deficiencies or because their employer chose to change the offering. Many Americans did not realize that the plans they had and liked had many deficiencies that the law corrected.

No one denies that the ACA could be made better. The first move should be to extend coverage to all Americans by some mechanism.  The ACA is a “mandate” which allows people to opt out by paying a small fine. If healthcare were an “entitlement” then the majority of the cost would be covered by tax dollars. Bernie tried to foster that conversation. Eventually a majority may accept that a tax increase to support an entitlement gives care to everyone and saves money compared to what they are now paying. Churchill said that you could always count on Americans doing the right thing after trying all the wrong things. We are pragmatic!

Recently, I attended a small meeting where I had an opportunity to talk with two people who had been executives in the NHS (the National Health Service). I realized from their stories that our fears about a single payer would be reduced if we understood that there is substantial local control and opportunity for creative variation within the NHS. The NHS is improving access and quality. It is not a perfect system and has many growing challenges, but it comes far closer than we do to achieving the call for:

Care better than we’ve seen, health better than we’ve ever known, cost we can afford…for every person, every time.

Cohen’s article suggests that the ACA is a noble but imperfect law that reduces the impact of income inequality. If you see the ACA as a start, you probably cringed when you read about the departure of Aetna from the exchanges. That news hurt, but the announcement this week that Dartmouth, home of Elliott Fisher who in 2006 coauthored the concept of the ACO, will no longer participate in any of the Medicare ACOs felt  like a more thematically significant injury. The departure of major insurers from some of the exchanges and the departure of several systems from the ranks of the ACOs, deserve closer examination if we are planning to improve the ACA.

In his blog Paul Krugman, the Nobel prize winning economist, writes that Obamacare has hit a bump. I agree with his explanations and concerns.

 

  • Obamacare is a system that relies on private insurance companies to provide much of its expanded coverage…

 

  • Many of these private insurers are now finding themselves losing money, because previously uninsured Americans … turn out to have been sicker and more in need of costly care than we realized. …

 

  • The problem is greater in states that have small populations and/or have governments hostile to reform, where the exit of insurers may leave markets without adequate competition.

To Klugman’s points I would add that many young people whose premium would have added to the funds to offset the expense of the sicker, newly insured, opted out either without penalty because of their poverty, or with too small a penalty because of the efforts of Congress to avoid more appropriate penalties that would have had a political downside that precluded the passage of the law. Krugman suggests increasing the subsidy both to individuals and to insurers to encourage greater participation and to put more money into the system. An alternative is to reconsider the public option. He believes that from an “economist’s viewpoint” both would be sensible repairs, but as he says those repairs seem unlikely because of the gridlocked Congress that we now have.  The combination of a Clinton victory with control of Congress is unlikely which passing ACA 2.0 anytime soon also unlikely.

The other “big bump” the ACA hit was the withdrawal of Dartmouth from all Medicare ACOs. The good news in my opinion is that many of the issues that have hampered ACO growth can be fixed CMS and do not require legislation. Let me ask you to read the NYT article, “Dropout by Dartmouth Raises Questions on Health Law Cost-Savings Effort” by Robert Pear explaining why  Dartmouth is pulling out.

Here are some points to notice:

 

  • In its quest to remake the nation’s health care system, the Obama administration has urged doctors and hospitals to band together to improve care and cut costs, using a model devised by researchers at Dartmouth College.

 

  • … Dartmouth itself, facing mounting financial losses in the federal program, has dropped out, raising questions about the future of …accountable care organizations,

 

  • Medicare now has more than 400 accountable care organizations, serving eight million of the 57 million Medicare beneficiaries. …officials say the new entities are saving money while improving care, but some independent experts have questioned those claims.

 

  • …Dartmouth’s accountable care organization had reduced Medicare spending on hospital stays, medical procedures, imaging and tests. And it achieved goals for the quality of care. But it was still subject to financial penalties because it did not meet money-saving benchmarks set by federal officials.

 

  • Since …2012, a number like Dartmouth have dropped out …, citing financial uncertainties and unrealistic benchmarks for spending. Organizations with higher levels of prior spending had a greater ability to achieve cost savings in the first years of the program, by reducing unnecessary services, so they were more likely to qualify for financial rewards…

 

In the near future I will describe my ACO experiences and why I believe ACOs can still be the a major factor in the improvement process. I asked Michael Soman, the retired President of Group Health’s Physicians Group to respond to the exit of Dartmouth from the Medicare ACOs. His cryptic reply:

Couple of things, and you don’t have to agree and you may not even like it. I am also affected in what I say by big insurers pulling out of the exchanges.

-reinforces that PPACA, while a definite couple of steps forward, is not good enough

-that the well-intended desire to go for incremental change while keeping the key financial stakeholders (drug companies, insurers, suppliers, hospital firms, docs) happy can’t fundamentally change the paradigm

-that intelligent academics (like Elliot F) can’t predict how margin-sensitive entities will respond to new incentives

-that one of the conundrums of incremental change here is punishing the organizations that were already achieving cost and quality goals

-that the amount of bureaucracy to monitor and administer incremental change is over-whelming and is money not spent on patients

-that the original sin was letting healthcare be a market governed entity in our country

-that we need a single payer and we can dance around it all we want but we must ultimately take the big step, risk the beatings, and do it.

At the end of his piece Globe piece Michael Cohen said:

Six years after the ACA took effect, it has, perhaps more than any law passed in the previous five decades, narrowed income inequality, saved lives, and reduced financial anxiety. Imagine if the help it provides could be reproduced with paid sick leave and family leave policies, a higher minimum wage, or affordable child care.

That sort of progress would truly further enhance the greatness of our society. What worries me is that if we are self serving, fearful of addressing complex issues and withdraw when we do not get a perfect outcome the first time around progress will be slow. If we elect authoritarian politicians who use fear to motivate people, we could reverse a lot of the good that has been accomplished over the past eight years.

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