remaking the affordable care act (aca); the future

REMAKING THE AFFORDABLE REMAKING THE AFFORDABLE CARE ACT (ACA); THE CARE ACT (ACA); THE

FUTUREFUTURE

Pauline Vaillancourt RosenauManagement , Policy, and Community Health

School of Public HealthUniversity of Texas Health Science Center

Houston, Texas, USA

September 21, 2011

www.prosenau.comEmail: [email protected]

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Pauline Rosenau; US Health System Reform 2011

OVERVIEW & DISCLAIMER

The ACA is a product of leaders, not the public

Repeal unlikely Predicting the future; surprising

evidence and policy assessments Employment Compensation

Supreme Court decisions predicted Future of Congressional action – less

predictable 2

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ACA IS A PRODUCT OF ACA IS A PRODUCT OF LEADERS, NOT THE PUBLICLEADERS, NOT THE PUBLIC

Public support low all along!Knowledge of the bill has declinedBroad public misinformation, February 2011

20% think the ACA already repealed 26% think if might have been, not sure 52% think it is still the law: February 2011 http://www.kff.org/kaiserpolls/upload/8156-F.pdf

47% say the bill “won’t make much difference” August 2011

Those to benefit most, either don’t know that or say 2014 is “too far away” 3


LIVING WITH THE ACA Wall Street expects agree: “repeal highly

unlikely” Implementation stretches from 2010 to

2020 States to do the heavy lifting – variation

Exchanges Rate increases, etc.

Default 4


FEW FEW STAKEHOLDERS STAKEHOLDERS WANT REPEAL!WANT REPEAL!

Few would benefit: Hospital groups Doctor groups Pharmaceutical manufacturers Employers Health insurers

Prefer to stay with it and make changes rather than repeal and/or start over

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WHY?WHY?The ACA is the “Law of the

Land” New business model required Costly investment up-front “Not to have it in your

strategic plan would be foolish”

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STATES AS STATES AS “STAKEHOLDERS”“STAKEHOLDERS”

Not like the others Less effective at lobbying

Late “to the table” Politically divided

Court challenges BUT will take the money ….. Governors get lots of flexibility

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HOW DID THE MD HOW DID THE MD COMMUNITY LINE UPCOMMUNITY LINE UP

Support: AAMC (Association of American Medical

Colleges) AMA – ACOG “qualified support” – “lots to like”

http://www.ama-assn.org/ama/pub/health-system-reform/hsr-impacts-practice.shtml

Did not supportTexas Medical Association – Austin

American- Statesman 22-23 March 2010

Physicians for a National Health Program http://www.pnhp.org/

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CAN HOSPITALS MAKE MONEY CAN HOSPITALS MAKE MONEY UNDER THE ACA?UNDER THE ACA?

Some say yes (Mahar 2010; Hackbarth 2009):

Efficiency and quality outcomes improve – payment increases

Coverage increases - reduce uncompensated care

Others say “no way” (Savings and Goodman 2010)

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EVIDENCE FROM MASSACHUSETTS; THE MECHANICS OF IMPLEMENTATION OF A

VERY SIMILAR HEALTH SYSTEM

Uninsured rates plummet Demand up Costs not controlled Newly insured stay with safety-net

providers and community clinics How to compete for “newly insured” (Arch.

Intern. Med .Aug 8/22 2011)

“Perceived quality and convenience”

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SURPRISE EMPLOYMENT SURPRISE EMPLOYMENT EFFECTS IN MASS.EFFECTS IN MASS.

Healthcare becoming the dominant employment sector: Staiger NEJM 9/2011

Administrative burden higher; increased demand for managers, administrators, and support personnel Staiger , NEJM Sept. 2011

Little increased demand for physicians and nurses Staiger , NEJM Sept.

2011

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PAYMENT SYSTEMS: MORE PAYMENT SYSTEMS: MORE “INNOVATIVE”, COMPLEX, AND “INNOVATIVE”, COMPLEX, AND

VARIED VARIED

More MDs on salary- at FQHCFewer fee-for-service systemsMore capitation paymentsBetter incentivized P4PSome ACOs for Medicare

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COMPENSATION COMPENSATION CONSIDERATIONS…CONSIDERATIONS…CONTINUEDCONTINUED

2013-2014: better payment for MedicaidOver time: Medicare payments unlikely

to remain as high as they are now If doctors refuse Medicare/Medicaid

patients, where will they go? Answer: stay with safety-net providers or

move to Federally Qualified Health Centers

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WHATWHAT WILL THE WILL THE SUPREME COURT DO?SUPREME COURT DO?

Court will hold the Mandate Unconstitutional by Dec. 2012: Intrade predicts the likelihood as 22.5% http://www.intrade.com/v4/markets/?eventId=89280#

Court will hold the Mandate Unconstitutional by Dec. 2013: Intrade predicts the likelihood as 50% http://www.intrade.com/v4/markets/?eventId=89280#

ACA is Constitutional All of the ACA is unconstitutional - unlikely

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WHENWHEN WILL THE WILL THE SUPREME COURT DO IT?SUPREME COURT DO IT?

Can take the case anytime: October through December 2011 - likely

Could rule before the 2012 election?

Could take the case in 2012 and then rule after the 2012 election?

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THE MANDATE MAY BE THE MANDATE MAY BE UNCONSTITUTIONALUNCONSTITUTIONAL

Pressure from insurers is on! Congress could fix it….

Buy now or pay more later ; late enrollment penalties, no uncompensated care reimbursed

Open enrollment expanded to two years or longer (Uccello)

Opt out without a penalty, for 5 years but results in big limits on individual (Starr)

Status quo – not required to purchase but 2 year preexisting conditions in effect

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2013 CONGRESS WILL DECIDE THE FUTURE OF MEDICINE

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WHAT WILL CONGRESS WHAT WILL CONGRESS DO AFTER THE 2012 DO AFTER THE 2012

ELECTION?ELECTION?

Who will be president?Which party will win the

House?Which party will win the

Senate?20


CONGRESS CAN WITHHOLD FUNDING FOR IMPLEMENTATION?

It already has for some elements

Pilot programs have gone unfunded

Not all new elements require funding

Absence of funding results in delay or “repeal” without the hassle

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CONGRESS CAN CHANGE THE ACA

Reduce subsidies to help low income people buy insurance Who’s against? Who’s for?

Reduce funds to the States Payments for Medicaid Exchanges

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remaking the affordable care act (aca); the future

Documents

national health program

overview disclaimerthe

aca wall street

affordable care act

product of leaders

repeal andor

future surprising evidence

bill wont