Health officials and policy analysts at a recent Brookings Institution panel discussion(www.brookings.edu) highlighted the benefits and shortcomings of the Patient Protection and Affordable Care Act (ACA) during an event held to mark the fifth anniversary of the law, which has helped an estimated 10 million people obtain health insurance.
Niam Yaraghi, Ph.D., (center) and Eric Patashnik, Ph.D., discuss the impact of the Patient Protection and Affordable Care Act on patient care and medical costs with moderator Elaine Kamarck.
Andy Slavitt, acting administrator for CMS, joined the agency when it was experiencing a major dilemma at the end of 2013. It was a crisis period, he said, because of problems associated with enrollment through the newly opened insurance exchanges.
Now, panelists said, the ACA has brought greater emphasis on primary care by precipitating two major changes: more insured individuals and payment incentives for avoiding emergency hospital visits.
"We need to be sure that the delivery system provides enough capacity in primary care, especially in rural and targeted urban areas," said Slavitt.
Changes in the health policy arena are occurring rapidly, yet individuals sometimes do not notice it, he added.
"When I go home to visit family in the Midwest, I tell them we are moving quickly and with an impact, but they don't believe me," Slavitt said.
- Panelists at a recent Brookings Institution event said the Patient Protection and Affordable Care Act precipitated major changes that place greater emphasis on primary care.
- They cited positive developments, including wider insurance coverage, improved access to care and a reduction in overall health costs.
- Political debate about the law continues to overshadow the innovations and new programs that were intended to the change the delivery of care and reduce overall costs, panelists said.
Increased competition and greater awareness will be beneficial, he noted -- for instance, by helping consumers understand new plans that have narrow physician networks and more limited benefits.
"What people ask most is, 'Is my doctor in the network and is my drug in the formulary?'" Slavitt said. "These questions need to be answered as easily as 'What is my deductible?'"
Eric Patashnik, Ph.D., a professor of public policy at the University of Virginia, gave a comprehensive analysis of the impact the legislation has had since its passage. He said the biggest surprise is that common predictions of both supporters and opponents proved to be wrong.
Opponents of the law said it would collapse of its own weight. Supporters said most people would applaud the initiative as individuals began enrolling in insurance plans.
The ACA brought positive developments, including wider insurance coverage, improved access to care and a reduction in overall health costs. And there are indirect benefits, such as coverage of children on their parents' plans until age 26 and the removal of pre-existing conditions as a disqualification for care under a new plan. But Patashnik noted that public opinion remains mixed.
"The fight over Obamacare is not over," Patashnik said.
Panelists compared the ACA to previous expansions of social services, including Social Security and Medicare.
Social Security was amended in 1939 and did not receive wide bipartisan support until the 1950s, when President Eisenhower said Republicans would no longer fight New Deal legislation. Medicare passed with strong majorities in 1965. The program was in full operation one year later, but it faced initial opposition from physicians, who had to be encouraged to participate, as well as the need to overcome issues related to segregation.
One of the sharpest contrasts between the ACA and previous social legislation is that the former has no clear constituency of individuals who identify themselves as beneficiaries, said Patashnik. With Medicare and Social Security, seniors were immediate supporters.
"It's not as if everyone says, 'I'm an ACA beneficiary in the same way they say, 'I'm a Social Security beneficiary,'" he said.
Moreover, said Patashnik, political debate about the law continues to overshadow innovations and new programs that were intended to change the delivery of care and reduce overall costs. He noted that the Patient-Centered Outcomes Research Institute established by the ACA, for example, is working to reduce wasteful spending but is having only limited impact, due largely to the fact that it was never given the authority to mandate system changes.
"The ACA was not designed to make it as transparent as possible and easy for people to buy into it," Patashnik said. "The ACA was designed primarily with passage in mind. It was designed to make it feasible to reform the pre-existing employer-based health care system, to retain that system but to bring more people into it."
Niam Yaraghi, Ph.D., a Brookings Center for Technology Innovation fellow, said one aspect of the law that draws widespread support is the innovative payment models to replace unsustainable fee-for-service. He added that policymakers could help increase adoption of innovations, such as electronic health records, by asking physicians to serve as advocates and demonstrate how changes could improve patient care.
Panelists said health care reform was meant to address the highest medical costs, but opposition from multiple interest groups was too intense to fully realize that goal. Steven Brill, an author who has written about health care, said CMS should be allowed to negotiate directly with the pharmaceutical companies, something the Obama administration sought but could not get included in the legislation.
In another attempt to cut costs, framers of the legislation considered hospital readmission rate penalties of 6 percent or 7 percent before the penalty was set at 1 percent, allowing hospitals with a 3 percent margin to earn revenue for a visit that could have been prevented, Brill said. A focus on lowering hospital readmission rates did lead to improvements, however.
"The good news about Obamacare is it allowed 10 million people to get health care, but it did nothing to bend the cost curve," he said.
On another topic, Brill noted that it is important for individuals to develop enough medical literacy to know how to select an insurance policy and improve their understanding of the process. Individuals tend to rely too heavily on the monthly premium cost when shopping for plans, he said. One problem is that the language used in many insurance plans is so complicated that even insurance executives cannot explain it.
"The least important of your costs is the monthly premium," Brill said. "Most people have no idea what a co-pay means. They have no idea whether their physician is in their network or whether their hospital is in the network."
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