Just 5 years ago, millions of Americans entered a new era of health care. The Affordable Care Act (ACA) was born and sold as the solution for improving health quality, controlling the rise of costs, and expanding access to care by making health insurance more affordable to most Americans. Let's pause for a moment and ask ourselves: Has it worked?
As emergency medicine residents, the answer is critical to our practice. We are the next generation of doctors, responsible for sustaining a highly utilized entry point into the health care system and advocating for patients in their most vulnerable moments, regardless of ability to pay. Our specialty is therefore measured by three key domains: (1) granting affordable access, (2) containing health costs, and (3) improving quality/health system performance. While the ACA was designed to address these areas, has it done so successfully?
“How easily can I see a doctor?” (Access to Care)
First, let's consider access to health care. The law expanded health coverage to millions of Americans thanks to more federal subsidies to the newly insured, the expansion of Medicaid plus COBRA coverage (for young Americans under 26 years of age) and new federal regulations prohibiting insurers from discriminating against people with pre-existing conditions. By February 2015, 11.7 million Americans had selected a new health plan via health insurance marketplaces.1 Surveys have shown greater satisfaction regarding coverage among these newly insured.
However, supply-side issues have made access to care a big challenge. Many health insurance plans restrict the ability for patients to see any doctor they want. Recent evidence also indicates challenging conditions for patients to meet with a primary care physician (PCP) as the number of scheduled acute care visits increases.2 If emergency department (ED) visits, utilization rates, and acuity all increase, prolonged waiting times for primary care appointments will only worsen patient access to care.
Paradoxically, current evidence indicates rising ED use among insured patients. In Massachusetts, one study found that ED visits rose between 0.2 – 2.2% every year after expanding coverage in 2006.3 Another study found 40% more visits to the ED during the first 18 months of coverage in the state of Oregon among Medicaid patients.4 Why? Patients perhaps feel more comfortable being evaluated by doctors, knowing their insurance will cover the cost.
“How well are we paying for medical care?” (Cost Containment)
Second, the ACA was designed to control costs. Pre-reform, U.S. per capita and GDP health costs far exceeded that of any other developed nation, reaching $8,745 per person annually and accounting for almost 18% of our GDP in 2012.5 Provider reimbursement was partly blamed for rising costs as evidence showed that traditional fee-for-service (FFS) lead to more tests and procedures but not necessarily improved outcomes or higher quality.6,7 Reimbursement is now being geared towards rewarding quality outcomes instead of quantity of services provided. As future attendings, we will be encouraged to work more closely with our medical colleagues and will likely be held accountable for the full hospital course of our patient rather than their ED visit alone.
Across our health care system, we are seeing some improvements with regard to cost containment. Fewer people now report bankruptcy due to medical expenses and our government provides subsidies to individuals/families earning 133-400% of the federal poverty level. Per capita health care expenditures have increased at historically low rates, as low as 3.2% annually from 2010-13 compared to 5.6% annually over the previous 10 years.8 However, many experts are bewildered to see overall health costs rising in some states despite lower spending for Medicare patients, suggesting that private market price agreements between insurers and hospitals may influence costs more than anything else.9
“Are we providing high-quality care?” (Quality)
The overall quality of health services was another target of the ACA through encouragement of innovation and new ideas. The Bill encourages us, as providers, to form new arrangements for Medicare patients that integrate and coordinate ambulatory, inpatient and outpatient services across specialties known as accountable care organizations (ACOs). Funding boosts for venerable programs (eg, $1.5 billion allotted to the National Health Service Corps) and the creation of new initiatives may improve healthcare quality. The Centers for Medicare & Medicaid Services (CMS), however, has had serious problems with implementing these new payment models. Both hospitals and physician organizations (including the American Medical Association and American Heart Association) have mounted criticism for the lack of flexibility and risk adjustment in the way providers are paid for quality of care, and thus continue to voice their concerns.10
Table 1. ACA Resources
| Podcasts | http://smhs.gwu.edu/urgentmatters/podcasts — Excellent series of podcasts hosted by policy expert Dr. Jesse Pines (G.W.) |
| http://www.thehealthcarepolicypodcast.com — Technical analyses on timely topics | |
| Websites | http://kff.org/health-reform — Excellent guide with useful graphs and illustrations https://ca.edubirdie.com/blog/about-the-aca. — Overview of the ACA by key topics |
| https://www.whitehouse.gov/health-care-meeting/proposal/whatsnew/overview — Simple overview directly from the White House | |
| Blogs | http://healthaffairs.org/blog — Good vehicle for commentary and analysis on health care |
| https://www.healthinsurance.org/blog — Quick articles on the latest health reform issues | |
| http://healthblog.ncpa.org — Updated, short blurbs on current issues | |
| http://theincidentaleconomist.com — Clever series of posts on research and reform | |
| Books | Obamacare Survival Guide: The Affordable Care Act and What It Means for You and Your Healthcare (By Nick J. Tate) |
| Reinventing American Health Care: How the Affordable Care Act Will Improve Our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System (By Ezekiel Emmanuel) |
The Future
As health reform implementation progresses, our system will continue to face significant challenges. A recent study found that some hospitals are finding ways to improve their Medicare reimbursement payments by underestimating their own rate of readmissions, placing patients into their observation areas instead of admitting them.11 Furthermore, executives are taking advantage of market conditions to gouge patients by drastically raising the prices of critical lifesaving drugs to improve profit margins (search “Martin Shkreli”). Even policymakers, and especially presidential candidates, have threatened the ability for states to provide health insurance to millions by placing controversial measures into federal legislation (eg, preventing the government from assisting insurance companies with financial losses).12 These problems may be here to stay.
Ultimately, success in the areas of access, cost containment, and quality of health care will depend on the balance of power between health system leaders, insurance companies, and patients. Health policy shapes our world by establishing policies, regulations and laws that define and incentivize how physicians deliver care. Even prior to the ACA, health policies drove the way we deliver care. Every president since Richard Nixon attempted to enact policies with similar goals (albeit in different ways). While the long-term impact of the ACA has yet to be realized, undoubtedly, it will affect all of us more than we can imagine.
References
- S. Department of Health & Human Services. Health Insurance Marketplace 2015 Open Enrollment Period: March Enrollment Report. https://aspe.hhs.gov/pdf-report/health-insurance-marketplace-2015-open-enrollment-period-march-enrollment-report. Accessed Jan. 29, 2016.
- Medford-Davis L, Eswaran V, Shah R, Dark C. The Patient Protection and Affordable Care Act's Effect on Emergency Medicine: A Synthesis of the Data. Ann Emerg Med. 2015;66(5):496-506.
- Smulowitz P, O'Malley J, Yang X, Landon B. Increased Use of the Emergency Department After Health Care Reform in Massachusetts. Ann Emerg Med. 2014;64(2):107-115.e3.
- Taubman S, Allen H, Wright B, Baicker K, Finkelstein A. Medicaid Increases Emergency-Department Use: Evidence from Oregon's Health Insurance Experiment. Science. 2014;343(6168):263-268.
- Potter W. The ”˜good old days' before Obamacare. Healthinsuranceorg. 2016. https://www.healthinsurance.org/blog/2014/10/25/the-good-old-days-before-obamacare/. Accessed Jan. 29, 2016.
- American Enterprise Institute. The Role of Medicare Fee-For-Service in Inefficient Health Care Delivery, 2016. http://www.aei.org/wp-content/uploads/2013/04/-the-role-of-medicare-feeforservice-in-inefficient-health-care-delivery_141413376272.pdf. Accessed Jan. 29, 2016.
- Robert Wood Johnson Foundation. How Does The Affordable Care Act Attempt To Control Health Care Costs? 2011. http://www.rwjf.org/en/library/research/2011/07/how-does-the-affordable-care-act-attempt-to-control-health-care-.html. Accessed Jan. 29, 2016.
- Hamel M, Blumenthal D, Collins S. Health Care Coverage under the Affordable Care Act: A Progress Report. N Engl J Med. 2014;371(3):275-281.
- Quealy K, Sanger-Katz M. The Experts Were Wrong About the Best Places for Better and Cheaper Health Care. The New York Times. http://www.nytimes.com/interactive/2015/12/15/upshot/the-best-places-for-better-cheaper-health-care-arent-what-experts-thought.html. Accessed Jan. 29, 2016.
- Miller H. Bundling Better: How Medicare Should Pay For Comprehensive Care (For Hip And Knee Surgery And Other Healthcare Needs). Center for Healthcare Quality & Payment Reform; 2016. http://www.chqpr.org/downloads/BundlingBetter.pdf. Accessed Jan. 29, 2016.
- Weaver C, Matthews A, McGinty T. Medicare Rules Reshape Hospital Admissions. The Wall Street Journal. http://www.wsj.com/articles/medicare-rules-reshape-hospital-admissions-1449024342. Accessed Jan. 29, 2016.
- Pear R. Marco Rubio Quietly Undermines Affordable Care Act. The New York Times. http://www.nytimes.com/2015/12/10/us/politics/marco-rubio-obamacare-affordable-care-act.html. Accessed Jan. 29, 2016.