The Affordable Care Act: Progress & Peril John E McDonough September 2015
Outline The Good News The Not So Good News Messages that Work Hope for the Future
Significant progress on coverage 1. Good News about the ACA US health spending at historically low growth rate ACA less expensive than projected Significant progress on health system transformation Dynamic period of experimentation federal, state, health sector Advancing the Triple Aim
US Adult Uninsurance Rate Down to 11.4% 4
Hitting the Right Targets People Getting Need It the Most Help the Most 5
Reductions in Coverage Inequities 6
ACA s Impact on Uninsurance in Kentucky Source: Kentucky Department for Medicaid Services 7
Getting Health Insurance under Titles I and II 8 http://www.nejm.org/doi/full/10.1056/nejmhpr1405667
New Estimates of ACA Coverage Costs Projected Costs Related to ACA Insurance Coverage Provisions (2014 2019): As of March 2010: $759 billion As of April 2014: $659 billion *13% reduction Source: CBO. (April 2014). Updated Estimates of the Effects of the Insurance Coverage Provisions of the Affordable Care Act. http://www.cbo.gov/sites/default/files/cbofiles/attachments/45231-aca_estimates.pdf 9
Health Care Reform and the Federal Deficit Source: Congressional Budget Office (April 2010) 10
All payers have seen lower spending increases Commonwealth Fund. Note: Figures for 2013 are projections. Source: Based on data from Bureau of Economic Analysis, National Income and Product Accounts; Centers for Medicare and Medicaid Services; Council of Economic Advisors. (Presented by Peter Orszag, Citigroup, at Altarum Institute Symposium on Sustainable U.S. Health Spending: The Quest for Value, July 15, 2014).
ACA Tax Increases in Context Source: Incidental Economist 12
Health System Performance Rankings 13
The Delivery System Reform Toolbox Reduced Payments for Avoidable Complications Value Based Purchasing Medicare Advantage Plan Bonuses Accountable Care Organizations Bundled Payments Hospital Inpatient Quality Reporting Physician Quality Reporting System Medical Homes Source: D. Blumenthal, Commonwealth Fund Meaningful Use 14
30-Day, All-Condition Medicare Readmission Rates ACA passed Penalties start Source: Niall Brennan, CMMS, Findings from Recent CMS Research on Medicare, Presentation at AcademyHealth Annual Research Meeting session on The Centers for Medicare and Medicaid Services Data and Information Products, June 9, 2014. Available at http://www.academyhealth.org/files/2014/monday/brennan.pdf Adapted from Commonwealth Fund.
50,000 Deaths Averted, by HAC: 2011-2013 16 Source: AHRQ National Scorecard Estimates from Medicare Patient Safety Monitoring System, National Healthcare Safety Network, and Healthcare Cost and Utilization Project. 2014
Pre-ACA System ACA System US Health Care s Changing Paradigms Fee for service Pay for performance No underlying system ethos Where We Are Moving Fee for Value Pay for Outcomes Accountable Care and The IHI Triple Aim to: Improve patient experience of care Lower per capita costs Improve population health 17
2. Not So Good News States struggling on Medicaid expansion Lack of continuing/ongoing support for hard work of access expansion Affordable Care Act is not affordable enough Urban Institute Political threats not over -- continuing lawsuits, 2016 elections Much more money for opponents than for ACA supporters on political mobilization
State Medicaid Expansion Decisions 19
MA Health Reform Saved Lives Changes in Mortality After Massachusetts Health Care Reform: A Quasi-experimental Study: Changes in Mortality After Massachusetts Health Care Reform In the first 4 years after Massachusetts implemented 2006 health reform law, state mortality decreased 2.9% compared with similar populations in states not expanding health coverage. MA health reform has prevented ~320 deaths per year one life saved for each 830 people gaining insurance. Figure Legend: Unadjusted mortality rates for adults aged 20 to 64 years in Massachusetts versus control group (2001 2010). The shaded band designates the beginning of the Massachusetts state health care reform in July 2006. Health care amenable mortality is as defined in Table 1 of the Supplement. Other-cause mortality contains all other causes of death not included in that definition. Ann Intern Med. 2014;160(9):585-593. doi:10.7326/m13-2275 Date of download: 5/7/2014 Copyright American College of Physicians. All rights reserved.
Income relative to federal poverty line Massachusetts required enrollee contributions as percent of income 100% 0% 2.01% 150 0 4.02 200 2.1 6.30 250 3-4 8.10 300 4.2 9.56 350 No cap 9.56 400 No cap 9.56 Over 400 No cap No cap Source: Urban Institute 2015 The ACA Is Not Affordable Enough ACA required enrollee contributions as percent of income
Urban Institute Recommendations Improve premium tax credits and cost-sharing reductions i.e.: Move Silver from 70% to 80% actuarial value Ease access to marketplace financial assistance for those affected by the family glitch Allow states the option to expand Medicaid to 100 percent of the federal poverty level instead of 138 percent Increase federal grants for information technology development and operation; education, outreach, and enrollment activities; and oversight and enforcement of insurance regulations
ACA Title Covered (#M) ACA Financial Impacts: 2010-2019 vs. 2016-2025 $ Spent ($B) $ Raised /Saved ($B) 1. Private Sector Coverage 16/10 $509 $833 $80.6 $210 2. Medicaid/CHIP 16/14 $458.8 $824 $52.7 $66 3. Medicare/Delivery Reform $54 $449.9 $879 4. Prevention/Public Health $18 $.8 5. Workforce $18.2 -- 6. M&M Fraud & Abuse $2.8 $7 7. Biologic Similars -- $7 8. CLASS -- $70.2 $0 9. Revenues -- $437.8 $718 Others (Interactions etc) 14.8 $92.8 $204 Ten Year Deficit Reduction -$124 -$137/353
3. Messages that Work The health care law is here to stay. We need to fix and improve it to make it work better. Remember what everyone likes No more exclusions for pre-existing conditions Staying on parents' plan until age 26 More women get coverage and preventive services without co-pays Limits on how much you can be required to pay out of pocket People can get insurance if they have a life-changing event and not locked into jobs We all need to do more on lowering the cost of healthcare Source: Community Catalyst
Partisan Divide on the ACA s Future 25
Knowledge of ACA Increases Its Favorability Source: Wendy Gross et al: Americans Attitudes Toward the Affordable Care Act. 2014 https://pprg.stanford.edu/wp-content/uploads/health-care-2012-knowledge-and-favorability.pdf 26
4. Hope for the Future Ted Kennedy in 1995 Leadership is about seeing and seizing opportunity where others see no pathway or hope. Big health sector players rarely take the lead they follow when it's safe to do so You are we are America s health justice movement It's never over. It's never done.
Health reform is the achievement of a movement The Health Justice Movement 100+ years in the making since Teddy Roosevelt Wins and losses mostly losses 1949, 1965, 1974, 1979, 1988-9, 1993-4, 1997 Like any movement: Ups and downs; Sharp, disagreements; No controlling legal authority Disciplined learning from prior failures 28
ACA & disparities/inequities, Mental health, women, more Cong. Jim Clyburn: the Civil Rights Act of the 21 st century More than half of U.S. uninsured are non-white and lower income Mental Health: the largest expansion of behavioral health coverage in a generation Sebelius Women s Health: greatest advance for women s health in a generation National Partnership for W&F Addiction-Substance Abuse: I don t think there s another illness that will be more affected by the ACA. McClellan Disability: The ACA undeniably changes the paradigm for working-age people with disabilities, who now do not need to choose between healthcare and a job. B. Otto 29
We re almost there 30