With the presidential campaign in high gear, the Affordable Care Act (ACA) has is regular part of speeches, debates, and rhetoric on the campaign trail – but the conversation is not necessarily advancing solutions for the next generation of healthcare problems we face.
Rhetoric from both the Republican and Democratic candidates reflects divided feelings over the ACA – leaving too little room to assess and continue to improve healthcare today. Republicans frequently call for repealing and replacing the law (although it is unclear with what), while some Democrats are promoting a single payer system. Neither approach acknowledges the reality of how the ACA is changing the healthcare landscape and how to realistically tackle the challenges that lay ahead.
Healthcare reform’s main aims were to provide coverage for the nearly 50 million Americans who were uninsured after the Great Recession, and to drive greater value in how we pay for health care services - and there is evidence that the ACA has begun accomplishing both goals.
As of May 2015, the Obama administration estimated that 16.4 million people had gained coverage, especially low-income individuals and minorities. This represents a historic decline in the rate of uninsured Americans from 16.2 percent in 2013 to 10.7 percent in early 2015, according to the Kaiser Family Foundation. The uninsured rate is expected to continue to decrease with the third open enrollment for the ACA Marketplaces just having ended. However, there are questions about the long-term viability of the Marketplaces with enrollment lower than originally projected, and national insurers casting doubts on future participation. Putting aside the rhetoric and strengthening the Marketplaces would achieve goals for both sides – to cover more of the uninsured, but through private coverage options. One immediate solution would be to shore up the ACA’s insurance premium stabilization programs to encourage insurers to participate in the Marketplaces and spur competition. And competition could help hold down premium growth – allowing more people to enroll in coverage.
The ACA also included programs and provisions to tackle ever-rising health care costs by incentivizing providers to move from a fee-for-service payment system to one that pays for the value by taking both the cost and quality of care delivered into account. The Catalyst for Payment Reform, a non-profit organization leading efforts to transform payments so they are connected to the value of care, reported that in 2013 just 11 percent of payments made by surveyed private insurers to providers were value-based. In 2014, that number jumped to almost 40 percent. These rapid changes illustrated the unprecedented levels of payment and care delivery innovation across the healthcare system.
Medicare is also playing a leading role in the movement to value by testing new payment models and programs. For instance, there are over 430 Medicare Accountable Care Organizations - networks of providers that coordinate care for patients and are held accountable for the cost and quality of care they deliver. Medicare is also operating a bundled payment program, in which a single payment covers providers who deliver care for a patient during a defined episode or time period, with over 1500 participating providers.
While these data are positive, health care costs continue to grow faster than the economy- and are capturing headlines every day with high out-of-pocket and drug costs, and rising premiums. Long-term solutions will require Congress and the administration to continue testing and scaling successful multi-payer payment and delivery reform models. Lines between public and private are also blurring as private payers play larger roles in federal programs. Restraining health spending in the coming years will require government and private payers and providers to make consistent changes to care delivery (we need care that places patients and communities at the center), how treatments are paid for (population based payments that incentivize health promotion and prevention), and how they are consumed (engage patients and caregivers in their care). Both sides have a role to play in enacting long-term solutions – if we can get past the myths and rhetoric driving much of the debate today.
Despite early progress and lessons learned from the ACA, extreme policy responses such as those often espoused on the campaign trail could jeopardize increases in coverage rates and public and private investments in testing new payment and delivery models, before policymakers and stakeholders can assess what is (and is not) working.
Ideologically driven rhetoric, which perpetuates myths and unproven claims, glosses over the reality of the marketplace today where more of the uninsured are covered, the shift to value-based payments, and new population health based approaches to care. To spur more productive political dialogue about healthcare in America, it is imperative to tackle erroneous claims and myths on both sides about the ACA. Evidence and research can cut through the rhetoric and compel policymakers to continue to enact regulatory and policy changes that can accomplish the larger goal of establishing a high-performing healthcare system that serves all populations equally.
Rawal is an adjunct assistant professor at Georgetown University and a principal at CapView Strategies and the author of the newly released book, The Affordable Care Act: Examining the Facts (ABC-CLIO; January 2016).