David Sandman

This week marks the 8th anniversary of the passage of the Affordable Care Act (ACA). It has been under siege ever since it passed.

The law survived many near-death experiences along the way, and escaped being struck down in its entirety by a single vote in the Supreme Court. Its future looked especially grim following the last federal election. President Trump had repeatedly vowed to repeal the ACA on “day one” of his new administration. With Republican majorities controlling both the Senate and the House, repeal did seem likely.

Last year was tumultuous, to say the least, with multiple attempts to repeal the ACA. Yet eight years on, the ACA is still the law of the land and it’s still largely intact. On its eighth birthday, there is a lot to celebrate.

Thanks to the ACA, about 20 million more Americans have health insurance coverage. Nationally, the uninsured rate dipped from 16% in 2010 to just 9% in 2016. States that opted to expand Medicaid have experienced particularly large reductions in uninsured rates compared with those that chose not to expand the program. Medicaid expansion states also saw larger coverage gains for specific vulnerable populations, including young adults, prescription drug users, people with HIV, veterans, children, low-income workers, and early retirees. And having coverage matters. Regardless of the type of insurance, having coverage means better access to care. Gaining coverage increased the probability of having a usual source of care by up to 86.5%.

In New York State, the uninsured rate dropped from about 11% to 5.4% , a historic low, between 2010 and 2016. Gains have been seen across all segments of New Yorkers, and in every county. And New York has seen a substantial decrease in premiums since the Affordable Care Act was implemented: rates for individuals were down 55% between 2014 and 2018.

More than 4.3 million New Yorkers enrolled in coverage for 2018 through the New York State of Health Marketplace; nearly 3 million of those enrolled in Medicaid. New York also is one of two states that implemented what we call the Essential Plan. For low-income New Yorkers who earn too much to qualify for Medicaid, the Essential Plan has been a popular free or low-cost ($20 per month) coverage alternative. Nearly 740,000 New Yorkers enrolled in the plan for 2018 coverage.

The coverage expansion is the centerpiece of the ACA, and the law has succeeded on that measure. Because of it, millions of Americans have better access to care, more financial security, and greater peace of mind. Families are no longer one serious illness away from being bankrupt.

For all of that remarkable progress, there is still work to be done to achieve the ACA’s full promise. Beyond coverage, the ACA was also intended to improve health care quality, reduce costs, and expand investments in public health. Its success on these measures is more mixed.

Improving quality

As a nation, there are some positive signs on health care quality. The latest National Healthcare Quality and Disparities Report from the Agency for Healthcare Research & Quality (AHRQ) found that the quality of health care improved overall in 2015 across measures related to patient-centered care, patient safety, healthy living, effective treatment, and care coordination. This means we’re doing better in areas like infant mortality; well-visits for kids; home care patients taking their medicine and walking around on their own; death from lung cancer, breast cancer, and colorectal cancer; and hospital admissions for diabetes and asthma, just to name a few. That’s all good news.

There’s bad news, too. Disparities in care and quality persist. Racial and ethnic differences have remained stubbornly stagnant on most quality measures, from cancer screenings to treatment for depression to blood pressure management. Americans from poor, low-income, and middle-income households still experience worse care than those from high-income households.

Reducing costs

As everyone knows, the costs of health care are staggering. Elisabeth Rosenthal’s groundbreaking 2013 New York Times series, Paying Till It Hurts, documented some common (and enraging) examples: colonoscopies that cost $3,500 apiece, when in other countries they cost a few hundred dollars. Hip replacements that cost Americans four times as much as the same procedure in Switzerland or France. C-sections three times as expensive as those performed in New Zealand or Britain. Nasal spray? $108. The list goes on and on.

And while you might reasonably be willing to pay more for better quality or outcomes, that’s not how the system works. Health care prices are not rational, or easy to find out. The late, great health economist Uwe Reinhardt characterized American hospital pricing as “chaos behind a veil of secrecy.” Prices instead are largely determined by market power. For example, a study of New York State’s hospitals found that hospital prices vary widely, and that a hospital’s market leverage is a key factor in the prices a hospital can command. Hospitals with high prices don’t necessarily have higher quality scores, and vice-versa.

Measures of health care affordability barely budged between 2006 and 2014. Just last week, a paper in the Journal of the American Medical Association concluded that “there is little evidence that efforts to reform U.S. health care delivery have had a meaningful influence on controlling health care spending and costs.”

In New York State, health care expenditures totaled $193 billion in 2014, up from $165 billion in 2009 and triple what they were in 1991. New York’s health care expenditures are the second-highest in the nation, after California, and per-capita health care expenditures are the eighth-highest. Premiums for employer-sponsored coverage in New York are the third-highest in the nation; the average premium for a family plan in 2016 was more than $19,000. Compared to the progress on coverage and quality, the news is less encouraging about spending.

Advancing public health and disease prevention

Health is determined by much more than health care, but our spending patterns don’t reflect that. While 40% of deaths are caused by modifiable behavior patterns that could be addressed by population health interventions, only 5% of our health care dollars have historically focused on public health.

So when the ACA included $15 billion in funding over 10 years for a Prevention and Public Health Fund, it felt like perhaps a change was in the air. Instead, the fund almost immediately became a target, and it has been raided repeatedly over the past eight years. Most of the $500 million allocated in 2010 was spent not on new prevention programs but to backfill program budgets that had previously been cut. In 2012, President Obama signed legislation that slashed the Prevention and Public Health Fund’s budget by $5 billion. The 21st Century Cures Act — which provided $1 billion for public health measures such as addressing the opioid crisis and shoring up funding for mental health services and suicide prevention — cut an additional $3.5 billion from the Fund in 2016. And the most recent budget bill passed by Congress last month takes away another $1.35 billion.

There are bright spots, of course. The Diabetes Prevention Program (DPP), a lifestyle modification program that is effective in reducing participants’ body weight and risk of developing diabetes, was subject to a federal evaluation. It was found that the health benefits and cost savings met the threshold for further expansion through the Medicare program; beginning next month, DPP services will be available through Medicare. And this year, Governor Cuomo’s executive budget proposal for 2019 includes potential funding for the program through New York Medicaid.

The eighth birthday of the ACA’s passage is cause for celebration. It sparked the largest expansion of health insurance coverage in history, yielding the lowest uninsured rates we’ve ever seen. And it’s been an emblem of resiliency, having survived constant efforts to repeal or undermine it. But when we blow out the candles on the birthday cake, it’s a good time to make wishes too. Wish that its promises on costs, quality, and public health can also come true.

By David Sandman, President and CEO, New York Health Foundation
Published in Medium on March 21, 2018

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