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President Obama Outlines Progress, Future of Affordable Care Act
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The United States "will be better off" due to the progress that the Affordable Care Act has made in addressing inadequacies in the health care system, according to a special communication issued by President Barack Obama, JD.
Published in JAMA, President Obama also urged future policy makers to continue this progress in order for the country to realize its maximum benefits.
"When I took office, health care costs had risen rapidly for decades, and tens of millions of Americans were uninsured," he wrote. "...The Affordable Care Act (ACA), has made substantial progress in addressing these challenges. Americans can now count on access to health coverage throughout their lives, and the federal government has an array of tools to bring the rise of health care costs under control. However, the work toward a high-quality, affordable, accessible health care system is not over."
Barack Obama
The President evaluated overall progress between 1963 and early 2016 and how to continue that progress in the future using research findings and data from government agencies. He also shared his experiences in changing health and public policy.
Obama reported that the rate of uninsured Americans declined by 43%, from 16% in 2010 to 9.1% in 2015; much of that decrease occurred after the ACA took effect. The number of uninsured Americans decreased from 49 million in 2010 to 29 million in 2015, marking the largest decrease since Medicare and Medicaid were created.
In addition, research has identified improvements in health, treatment and financial security for those who have enrolled. For Americans who were already insured, research has shown improved coverage, including maternity care, preventive services and mental health care.
Obama also noted that the ACA has reformed the health care delivery system, particularly in terms of payment.
Approximately 30% of traditional Medicare payments currently move through alternative payment models, such as accountable care organizations and bundled payments, compared to virtually 0% in 2010.
The reforms have led to "a sustained period of slow growth in per-enrollee health care spending," as well as lower-than-expected health care spending in general and health care quality improvements.
"Despite this progress, too many Americans still strain to pay for their physician visits and prescriptions, cover their deductibles, or pay their monthly insurance bills; struggle to navigate a complex, sometimes bewildering system; and remain uninsured," Obama said.
He called for more work to reform the system, and offered some suggestions, including flexibility with adjustments as the most recent reforms have not reached their full effects, more financial assistance to help Americans who are unable to afford coverage, enhanced competition in the Marketplaces and legislative action regarding prescription drug costs.
Obama had an additional suggestion for Congress.
"There is another important role for Congress: it should avoid moving backward on health reform," he said. "While I have always been interested in improving the law — and signed 19 bills that do just that — my administration has spent considerable time in the last several years opposing more than 60 attempts to repeal parts or all of the ACA, time that could have been better spent working to improve our health care system and the economy."
Obama also shared lessons that he has learned throughout the ACA process, noting that he has "put them into practice in both health care policy and other areas of public policy throughout my presidency."
He noted the difficulty of change in general and stressed the need for cooperation instead of obstruction; that special interests, such as the pharmaceutical industry, are a threat to change; and that pragmatism is essential and benefits are typically greatest when common ground is found.
The President acknowledged that his lessons may feel discouraging, he is optimistic about the country and its "capacity to make meaningful progress on even the biggest public policy changes."
"I will repeat what I said 4 years ago when the Supreme Court upheld the ACA: I am as confident as ever that looking back 20 years from now, the nation will be better off because of having the courage to pass this law and persevere," Obama concluded. "As this progress with health care reform in the United States demonstrates, faith in responsibility, belief in opportunity, and ability to unite around common values are what makes this nation great."
Howard Bauchner, MD, editor in chief of JAMA, wrote in an accompanying editorial that authors of three additional editorials agree that the ACA has fulfilled its primary goal of providing more Americans with health insurance.
"There is less agreement on the cost of health care, with differences of opinion emerging about the increase in health care cost in Medicaid and Medicare vs. private insurance, and whether the apparent slowing of the increase in health care costs in Medicaid and Medicare is attributable to the ACA or to the recent economic recession," Bauchner wrote. "Given the many remarkable advances in health care and the cost associated with them, it may never be possible to understand the effect of the ACA on cost, particularly as more time passes since the enactment of the ACA."
Peter Orszag, PhD, former director of the Office of Management and Budget under President Obama, wrote that "fundamentally, the ACA is working," and outlined several surprises that have arisen since the ACA took effect.
They included a decrease in health care costs, improvement in the quality of health care, resiliency in employer-sponsored plans and a substantial increase in Medicare Advantage Enrollment.
"The US health care reform glass is more than half full," Orszag concluded. "Despite ongoing and legitimate concerns about the public exchanges, the ACA has proven remarkably successful at boosting coverage and reforming the delivery system."
Stuart M. Butler, PhD, MA, a senior fellow in economic studies at the Brookings Institution and former director of the Center for Policy Innovation at The Heritage Foundation, shared a list of aspects of the ACA that need to be revamped.
He said that subsidies should be changed so that they are easier to understand and make coverage more affordable; the tax exclusion for employees with employer-sponsored insurance should be replaced with a refundable tax credit; the Independent Payment Advisory Board should be replaced with a "premium support system" for Medicare; and the ACA should also be seen as a program that promotes health. He also called for increased federalism within the health care system and flexibility for private plans.
"It is both pragmatic and principled to recognize that achieving agreement on how to redesign an economy that large, or to do it successfully in one piece of legislation, is beyond the capabilities of the federal government," Butler wrote. "That is why core parts of the ACA need to be reassessed and revised and why empowering the US system of federalism to adapt and experiment with the law is so important."
Jonathan Skinner, PhD, the James O. Freedman Presidential Professor of Economics at Dartmouth, and Amitabh Chandra, PhD, Malcolm Wiener Professor of Social Policy at the Harvard Kennedy School of Government, wrote that the President should be pleased with what the ACA has accomplished.
"The nation is better off with the ACA, despite its shortcomings, than without," they said. "But health insurance, health care, and health, although often used interchangeably, are not the same. Even though the ACA has, to this point, not accomplished its goal of making health care more affordable, it is also far more moderate, innovative — and difficult to replace — than its critics claim." – by Chelsea Frajerman Pardes
Additional references:
Bauchner H. JAMA. 2016;doi:10.1001/jama.2016.9872.
Butler SM. JAMA. 2016;doi:10.1001/jama.2016.9881.
Orszag PR. JAMA. 2016;doi:10.1001/jama.2016.9876.
Skinner J, Chandra A. JAMA. 2016;doi:10.1001/jama.2016.10158.
Disclosures: Butler reports no relevant financial disclosures. Chandra reports serving on the Panel of Health Advisors for the Congressional Budget Office; consulting for Precision Health Economics; and receiving personal fees from Biogen, Vertex, Pharmaceutical Care Management Association, and Novo Nordisk. Orszag served as the director of the Office of Management and Budget under President Obama and has also served as the director of the Congressional Budget Office. Skinner reports being an investor in Dorsata and an unpaid member of the Altarum Institute's National Advisory Committee. Please see the full study for President Obama's public financial disclosure report for 2015.
Perspective
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Michael S. Saag, MD
In an issue of JAMA published in July, President Obama laid out the progress made in the delivery of health care since the passage of the Affordable Care Act in 2010. In the article, he also reviewed continued challenges and barriers of care that remain for a number of people in the United States.
Whether someone is ‘for’ or ‘against’ the ACA, the change that has been enacted in the health care delivery system is now immutable. Despite calls for repeals of ‘Obamacare,’ there is really no way to undo the changes that have occurred without causing tremendous harm to a large number of people, in particular, those who did not have health insurance prior to the ACA. We as providers of care to those with infectious diseases — HIV and hepatitis C — need to be aware of those changes and help the country modify delivery of care through continued changes to the ACA to help those most in need of our services.
The progress in terms of numbers of people who did not have health care coverage prior to the passage of the ACA and now is remarkable. A large number of these people are in states where Medicaid was expanded, thereby allowing the state to cover those who have up to 138% of poverty level into Medicaid, a substantial change from what most states were able to do previously. That large increase was covered by the federal government and will remain covered by the federal government, over 90%, in outgoing years.
The additional coverage of the ACA helped a number of individuals who previously couldn’t gain insurance due to preexisting conditions and helped those who had catastrophic diseases, where previously a cap on spending per individual was set. These caps for coverage are no longer legal. Therefore, many fewer people are going bankrupt personally owing to a medical bill. This is a great stride forward.
On the other hand, some individuals who previously had health insurance coverage are finding their premiums jumped significantly. The prior insurance policies they were participating in had caps on spending in a given year and they did not allow preexisting conditions. Under the ACA, it was permitted for those plans to continue going forward but new plans had to be compliant with rules of caps and open coverage. As it turned out, every insurance company participating in the exchanges made a decision to convert all their prior existing policies to compliance with the ACA. As such, the cost of running those policies increased and premiums went up proportionately.
While some felt put off by these increased premiums, it is clear those who needed extensive coverage due to catastrophic condition or developed a condition requiring a change of insurance plan found these new regulations allowed them to get coverage when they wouldn’t have before. It’s all a balancing act.
For those of us that take care of HIV-infected patients, not much has changed owing to the Ryan White CARE Act, where ‘coverage gaps’ are paid for by the Ryan White program (with the exception of inpatient care). For those of us practicing ID or HCV care, these changes are quite impactful. Many patients who did not previously have coverage now do and are able to access us in a more direct way. They no longer require ‘charity care’ to gain access.
While there are differences in the degree of coverage for HCV medications, for example, from Medicaid program to Medicaid program, there is a slow adoption of coverage of HCV direct-acting antivirals by Medicaid service providers and in most states as well as by Medicare. I imagine over the next 4 years Medicare will fully cover DAAs for all patients who are eligible and most Medicaid programs that have expanded services in conjunction with the ACA will be covering DAA therapy for all patients regardless of fibrosis stage.
Despite these advances, there is still a lot of work to do. Our health care system is still fragmented, inefficient, hard to understand and chaotic. Costs are unpredictable, especially cost of medications. We, as a society, need to gain control of how we are spending our dollars, not only for access to care but how to pay for very expensive medications that continue to go up by at least 7% every year. This is especially true for ‘specialty medications,’ like those that treat HCV, other difficult-to-treat infections and cancer chemotherapies.
We as a society need to decide how much the public should be involved in drug pricing, a concept heretofore deemed off limits by the pharmaceutical industry and Congress. However, Congress and the U.S. public are finding themselves paying more and more of the bill for health care in the United States, especially if a public option made available as proposed by Obama in his recent JAMA article. I believe the public should have a say in the pricing of pharmaceutical drugs, especially those new ones directed at specialty diseases. After all, Medicare and other payers certainly dictate what providers, hospitals and health systems receive for providing care.
The debate will continue, and hopefully we will find a way to harness the expanding costs of care and make health care more affordable, accessible and less chaotic for the United States in the future.
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