Let’s face it—with just a few weeks to go until Election Day, most of the conversations about the Affordable Care Act (ACA) are about its impact on our state and national politics and its use as a campaign issue.
Despite this challenge, and acknowledging the legitimate role of political debate regarding the ACA, it is critical that we begin having less politicized discussions about the ACA because of its impact on the economy (health care comprises one sixth of our GDP) and its impact on access, delivery, cost and the quality of health care in this country.
When the ACA was signed into law, supporters intended that it would improve access to care by lowering the uninsured rate, improve health care quality and outcomes, and lower costs.
Therefore we should ask: Are the original intentions of the law being realized or has the ACA created some unintended effects that counteract or make it more difficult to achieve these goals?
To date, much of the debate, research and study regarding the ACA that has found its way into the media and public consciousness has been conducted to support specific political positions. Not enough research has been done in an objective, or un-biased manner. This article lays out a series of key facts that we know about the ACA today and posits a series of questions that need answers so we can conduct an objective analysis of the ACA and better understand its true implications for our health system moving forward.
The ACA increases access to health insurance coverage through a combination of the establishment of health insurance exchanges with federal cost subsidies, expansion of the Medicaid program, consumer protections such as prohibiting the denial of coverage for those with pre-existing conditions, and mandating that individuals purchase insurance. In May the Urban Institute Health Policy Center estimated that 8 million individuals signed up for health insurance through the new exchanges and another 4.8 million enrolled in Medicaid. Just recently it was reported that of the 8 million who signed up, 7.3 million ultimately obtained insurance. With an estimated 45 million previously uninsured Americans, a reduction of 12 million seems an important step.
However, we do not know whether the goal of expanded access has actually occurred. Of the 12 million “new” enrollees, how many of them were previously insured and simply switched from one insurance plan to another? Complicating the assessment, certain individuals lost insurance because their policies no longer met the ACA insurance guidelines.
While there have been many estimates released on the net number of newly insured individuals, they vary greatly and are typically released by politically inclined institutions. To truly answer the question of whether the ACA substantially reduced the number of uninsured, independent researchers need to collect data and conduct analyses in a manner that is objective and transparent.
Further complicating the question of expanded access is the fact that access to health insurance coverage or reduced uninsured rates do not necessarily equate to access to health care. Access to health care is far more nuanced than merely increasing the number of people with health insurance. While having coverage is the critical first step, it is not the goal. The goal is actually getting health care when you need or want it.
One of the most important factors that can inhibit access to health care is cost. Access can be significantly improved or impaired based upon the lowering or raising of financial barriers to care. Recent analyses by Avalere show that a single individual enrolled in a “Silver” exchange plan faces an average annual deductible of $2,550. For those enrolled in “Bronze” exchange plans, the average deductible is $5,150. Additionally, in most ACA plans (as well as in many non-ACA plans), patients are required to pay a 40 percent coinsurance rate for drugs in tiers 3 and 4 (non-preferred branded medications and higher cost specialty drugs.) With certain medications costing hundreds to thousands of dollars each month, the amount paid by patients can be substantial. Therefore, the question we must answer is do high deductibles and coinsurance rates create barriers to care? Do people, despite having insurance, not go to the doctor or fill a prescription based on these realities?
Another key to an objective understanding of the impact of the ACA on access to care is having the right data for study. Unfortunately, most administrative or claims databases by a single insurance company or by a Medicaid plan lack the necessary data elements. An ideal database would show the care patients received over time before and after the ACA. Even more challenging, can databases capture the care of those patients who previously lacked insurance and track them forward in time where they gain insurance? No single insurance database will likely have all of this information. One way that was previously suggested to address this challenge was the adoption of a universal patient identifier. Patients may change from one insurance plan to another or one provider group to another, but the identifier would remain constant and enable longitudinal assessment of treatment patterns. However, real concerns about patient privacy—during the health debate in 1996 and ACA—subsequently sidetracked this national initiative.
With regard to the other aims of the ACA – to improve quality and outcomes and lower costs – the law has set in motion a number of new demonstration and pilot projects to improve provider reimbursement and delivery models. New reimbursement models seek to shift payment from traditional fee-for-service, to various performance-based approaches. These latter models, such as the Medicare Shared Savings Program (MSSP), consist of a fixed payment to providers for managing an episode of care, with additional payments based upon achieving certain quality benchmarks. These incentives may lead to reductions in overuse, a laudable goal. But, if quality measures are set incorrectly or are not comprehensive enough, they may also lead to areas of underuse, especially for those patients where treatment choices represent costly services. Many of these costly areas currently lack quality measures in the MSSP, and monitoring for underuse becomes quite difficult.
Ideally, the new performance-based models will achieve the optimal balance of efficient resource use with improvements in quality of care. However, without examining actual patterns of treatment, it will be difficult to assess whether this has been achieved. Once again, finding a database represents a significant challenge. Even more challenging, can those databases assess both appropriateness of services rendered and when necessary care has not been provided?
These are only a handful of the questions that need to be answered to determine the true impact of the ACA. The ACA aims to influence the trajectory of over one sixth of the US economy. As this extensive change occurs, many new questions will emerge and it is critical that we are able to conduct objective, data-driven research on the impact of the law and its policies. Organizations such as the National Institutes of Health (NIH) and the Patient Centered Outcomes Research Institute (PCORI) should fund such assessments and researchers must then rigorously conduct the studies, and policymakers review the ensuing evidence to understand whether the ACA is achieving the desired intended consequences, and hopefully avoiding some of the most worrisome unintended ones.
This approach will require a departure from the politically driven conversations about the ACA that are commonplace today. It is imperative that we meet this challenge and broaden the discussion because it is clear we do not yet understand the actual impact of the law on our health care system and whether it is meeting its intended goals, falling short, or creating unintended effects that need addressing. There is more work to be done, better tools need to be created so we can conduct a better assessment of the law, and while there is a role for political debate about the ACA, objective research-based study of the law’s impact will be most beneficial to improving the health system in the long run.
Dr. Robert Dubois is the Chief Science Officer at the National Pharmaceutical Council, a Washington, DC-based health care policy research organization dedicated to the advancement of good evidence and science, and to fostering an environment in the United States that supports medical innovation.