A recent article in the New England Journal of Medicine offers us food for thought as we contemplate the Affordable Care Act (ACA) at five years and look forward to its next challenges in 2016. If you have not read it, the article is entitled “Health Care Reform’s Unfinished Work- Remaining Barriers to Coverage and Access”, by Dr. B. D. Sommers from the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health. Fortunately it is an “open access” article that anyone can read whether they are a subscriber or not. Below you can read a condensation of the article with my comments.
Dr. Sommers begins by succinctly saluting the great accomplishments of the ACA and summarizing its failures. He notes,
“The U.S. uninsured rate is lower than ever, and coverage gains appear to be improving access to primary care and medications, affordability of care, and self-reported health. But challenges for health care reform persist: millions of Americans are still uninsured, and even for those with coverage, substantial barriers remain to obtaining affordable, high-quality care.”
There is a great combination of pie charts that shows who was helped and where the problems still exist because “..more than 30 million U.S. children and adults still lack insurance…” The article goes on to review, “Who are they, and what policy options exist for covering them?” Those who are still uninsured include low-income adults in the 20 states that have not expanded Medicaid under the ADA; millions of undocumented immigrants without healthcare; people who are not aware of the ACA’s coverage options, and those for whom the cost of care is a continuing barrier.
It is worth emphasizing that although access is improved the cost overall and the cost to individuals has not improved and is anticipated to get worse. Many patients theoretically have access but the product they have purchased has cost barriers to better care.
Meanwhile, even for people who gained insurance under the ACA and the tens of millions who already had coverage, substantial barriers to timely access to affordable medical care remain. Two features of exchange-based coverage — high cost sharing and narrow provider networks — can limit access and are increasingly common in employer-sponsored plans as well.
Deductibles that averaged about $3000 in 2015 for “silver” plans and $5,200 for “bronze-level” plans have probably had had a big impact that has reduced the use of unnecessary care but have also caused many to avoid care that they needed, despite elements of the ACA to prevent that reality by exempting preventative care from the deductible calculations. Dr. Sommers also points out that although “narrow network” products help keep prices down they may also exclude access to necessary specialty care. Cost also remains an issue in Medicaid where low reimbursement rates diminish access.
Many of these concerns that are easier to recognize after the ACA has had five years of road testing should be fixed. They would be except for the continuing political debates. This year may be lost as we pause for the election process. Some people still favor a single-payer model and Colorado has a single-payer model on its ballot despite the experience in Vermont.
Sommers speculates that even though “repeal and replace” is an appealing political slogan for some conservative politicians:
“…the almost-certain backlash against taking coverage away from more than 15 million Americans makes it hard to imagine this rhetoric becoming reality, even if Republicans control Congress and the White House after 2016.”
Sommers predicts “incremental change” and makes suggestions throughout his article.
- Several Republican-led states are still seeking compromises to expand Medicaid, and the Obama administration can continue to facilitate Medicaid expansion in conservative states by supporting flexibility for alternative approaches. As a stopgap, Congress could extend insurance tax credits to persons living below the poverty level who are not Medicaid-eligible, though they might find even heavily subsidized premiums unaffordable.
- Some people with higher incomes qualify for little or no premium subsidy for exchange coverage. Facing a penalty that remains substantially lower than a year’s worth of premiums, some have decided against purchasing coverage. Policy options here include increasing subsidies for higher-income families and strengthening the mandate that individuals obtain insurance — though the former would be quite costly and the latter would further antagonize most opponents of the mandate.
- Another alternative is replacing the mandate with incentives similar to those in Medicare Parts B and D: higher premiums for each month that a person chooses not to obtain coverage. But it’s unclear how easy it would be to implement such a policy for people younger than 65 who regularly cycle in and out of coverage, unlike the Medicare population.
- Efforts to control health care costs and thus premium growth will help determine whether coverage rates continue to climb.
- Sensible plan design would…encourage ongoing management for chronic conditions….such as diabetes, heart disease, and hypertension, without patients first having to exhaust several thousand dollars in out-of-pocket spending.
This article should help us focus on the work ahead as we face 2016 and ask ourselves what we should do next if we are to experience the benefits of the Triple Aim:
Care better than we have ever seen, health better than we have ever known, cost we can all afford: for every person, every time.
Despite improvement for many through the passage of the ACA what has been gained remains at risk until we control the cost of care to reduce the burden on those who now have access as we continue to search for affordable ways to enroll the thirty million people among us who continue without access to care. One way to join a movement that might make progress toward such a lofty goal is to ask the question, “What part of the problem am I?” or “What part of the problem is my practice or organization?”
Those are scary questions. We would rather see the need for improvement in others than in ourselves but the o nly areas of improvement where what you decide to do today, you can start today, is in those areas where you are the focus of improvement! Many movements seek to get other people to change. If we want a real movement toward universal coverage with high quality care for everyone at a sustainable cost the first changes must be within ourselves and within our own organizations. There is much that can be accomplished through reworking the ACA, but the cost issue is within the control of healthcare itself, no matter what finance mechanism is used along the spectrum of payment, from Fee For Service to “single payer”. Eliminating waste and improving outcomes requires no amendments to the ACA. We can get there through the science of continuous improvement and the exercise of better stewardship of resources at the personal and the institutional level. Those improvements are a choice that we can make no matter what Congress does.
The ACA is a start, not a destination. It will be up to us working together in 2016 to begin to deliver on the promise it offered as a product of rapid prototyping back in 2010.
