Where Do We Go From Here?

There is no denying that the Affordable Health Care Act is one of the most hotly debated issues in this year’s presidential election. It is also true that it has increased access to health care for millions of Americans. However, many questions remain when it comes to the health care law of the land. “Has it improved the quality of care that patients receive?” “Has it provided adequate coverage for a class of previously uninsured Americans or has it simply created a class of the under insured?” “Does the law do what it set out to do or will it have created a system so problematic that we won’t realize it until there is no turning back?”

Here’s the reality. We now have millions of underinsured Americans enrolled in health care plans through exchanges that don’t provide adequate coverage. The only coverage most of these Americans can afford is in the form of high-deductible bronze and silver plans that push upfront “first coverage” cost onto the consumer and only provide catastrophic coverage. Many times, this results in the inability for these patients to pay the collectable portion of their care and leaves the hospital or medical provider holding the bag. In fact, a recent study from Citi predicts that bad debt could reach $200 billion by 2019, making it more likely for providers to reject patients enrolled in these plans.

In addition, as many of these underinsured Americans are also newly insured, they have not received ongoing preventive care, often resulting in a higher number of claims when first insured. In fact, the largest health insurer in the United States, United Health Care recently announced that it plans to exit most exchanges by 2017, having previously stated losses of upwards of $475 million in 2015 and projecting $500 million in losses this year.

Finally, what has also started to happen is that commercial insurance companies are coming to hospitals asking for the hospital to take less reimbursement for the claims through the insurance exchanges in which they participate. The reality is that payments made by the commercial insurance companies have historically helped to subsidize the gap between government support and the uninsured.

Yet, amidst the financial losses has come an increase in quality of care provided. This is, in part, due to the increase in the consumer-driven marketplace and a shift from volume to value. Also, as part of new payment models from the Centers for Medicare and Medicaid Services, the government has put incentives in place that reward those who provide better outcomes for their patients, less complications. This has also changed the way we orient around the patient and the quality of care we provide. In fact, there has been a 17% reduction in hospital-acquired conditions since 2010, which seems to imply that the increased pressure on hospital safety has positively affected patient care. In addition, CMS’ Bundled Payment for Care Improvement Initiative links payments for multiples services a patient receives during an episode of care. Here, medical providers enter into payment arrangements that include financial and performance accountability for episodes of care. This payment model is most commonly put into practice in regards to an orthopedic procedure. By bundling payments for the services around, say a knee replacement, quality of patient care is likely to increase while there is likely to be a reduction in cost.

So the real question becomes: how do we provide health care and health coverage for as many people as possible that is affordable for the consumer without stratospheric losses to insurance carriers?

First, in order to reduce the cost of health care in a substantial and meaningful way, there needs to be legislative reform. This includes changing the interstate commerce laws so business can purchase health insurance across state lines, and enacting tort reform at the federal level to protect our physicians and hospitals from frivolous lawsuits. This will enable doctors to leave behind defensive medicine — ordering tests or procedures to protect them from the potential patient plaintiff.

Second, we need to promote health and wellness programs as a way to reduce health care costs down the road. We need to offer opportunities to teach people to make better health-related decisions including diet and exercise. We also need to make people more accountable for their own health and wellness—rewarding the achievement of certain benchmarks tied to good health.

Third, we need to reevaluate the law requiring an employer to offer health insurance to any employee working more than 29 hours per week. Complying with this law can be incredibly expensive and is forcing employers to minimize part-time help and move to contract employees.  

Finally, we need to create specific health care programs through the federal government for the 30 to 40 million uninsured while allowing these programs to be run at the state level based on the need of each individual state.

Back to the simple truth: no change will happen in the last seven months of our president’s final term in office. Change will only happen after January 20th. Creating a law, that from the start was underfunded, and then trying to fund it through higher taxes, reducing provider payments to providers and eliminating certain subsidies from payers weakens the entire health care system. It actually makes you think this current administration was gunning for a single payer system.

In closing, the next President of the United States will need to take on this political hot potato and initiate some needed reform.