What Obamacare Didn’t Do

The Affordable Care Act is a milestone package of health reforms. It’s a major expansion of health coverage. 

And according to one “60 Minutes” guest, it’s also an outrage.

“It doesn’t do anything on medical malpractice reform,” author Steven Brill told the venerable news program in January. “It doesn’t do anything to control drug prices. It doesn’t do anything to control hospital profits.”

The “60 Minutes” report missed the mark — several experts said the criticisms were misguided — but one critical point stands. Whether stymied by politics or the challenges of implementation, the law has failed to realize some of its most ambitious goals. The landmark health reform hasn’t done all that it could to reform health.

That’s been somewhat overlooked by supporters of the ACA, especially this month. In some corners of the media, the five-year anniversary of the health law turned into an uncritical valedictory for Obamacare, and specifically its insurance expansion.

Here’s a look at what Obamacare explicitly hasn’t done — and in some cases, still needs to do.

Coverage Expansion

The law is sometimes presented — even by the president — as the nation’s path to universal coverage.

But that’s not quite the reality. Yes, the uninsured rate has plunged. Covered California has helped millions of state residents get covered. But there are still huge gaps in the system: As many as 3 million Californians remain uninsured. And the rate of enrollment in the ACA’s insurance exchanges appears to be slowing down, Margot Sanger-Katz reports for the New York Times “Upshot” blog. For example, Covered California in 2015 only increased enrollment by one percentage point, despite making significant investments in outreach.

“The low-hanging fruit have already been gotten,” said Heather Howard, the director of the State Health Reform Assistance Network at Princeton University.

Many of the still-uninsured Californians are minorities or undocumented immigrants. Reaching these communities through the language and cultural barriers is a huge looming challenge for the state, say advocates.

“Enrollment entities should focus on communities of color as well as groups like young adults, who are more likely to experience a life event,” a new Health Access California report argues. The organization also calls on the state to focus on covering undocumented immigrants, who are explicitly left out of the ACA. “While California has taken some steps to correct this injustice, much more needs to be done,” according to Health Access.

“It’s critical for the health system as a whole for everyone to be insured,” Health Access Executive Director Anthony Wright told California Healthline earlier this week. “The system is stronger when everyone’s included.”

Payment Reform

The ACA also funded $10 billion for Medicare’s new innovation center — “the big player in health care delivery reform,” writes Chris Langston, the program director for the John Hartford Foundation. But many of the center’s payment pilots have yet to reap obvious rewards.

For instance, the center made a $1 billion investment in its Partnership for Patients Program, and CMS has trumpeted the initiative’s effect on reducing readmissions and boosting patient outcomes.

But “given the publicly available data and the approach CMS used, it’s nearly impossible to tell whether the PPP actually led to better care,” argue Peter Provonost and Ashish Jha.

“The PPP’s weak study design and methods, combined with a lack of transparency and rigor in evaluation, make it difficult to determine whether the program improved care,” the two quality experts wrote in the New England Journal of Medicine last year. “Such deficiencies result in a failure to learn from improvement efforts and stifle progress toward a safer, more effective health care system.”

While somewhat predictable, the lack of actionable insights from early payment pilots has complicated one of the ACA’s chief goals, which was to make U.S. health care more efficient.

“One clear aim of the law, for instance, was to shove health care away from the practice of paying for each test and procedure,” wrote Peter Orszag, a former Obama administration cabinet official. “[W]hen we pay for quantity that’s what we get.”

Orszag and others have suggested that the White House hadn’t done enough to bake the ACA’s planned payment reforms into law. But this may be changing. Earlier this year, the Obama administration set new targets on transitioning Medicare away from fee-for-service reimbursement and toward value-based payment.

“How big a deal it is depends on whether the value payment targets get met and whether the payment changes meaningfully shift how health care is delivered,” said Larry Levitt of the Kaiser Family Foundation.

“But the simple act of setting targets means the federal government is going to work to meet them and place a greater emphasis on value-based payment. This is also going to force an important discussion of how to measure health care quality.”

Care Quality

Some supporters of the ACA have said that the law isn’t really “health reform” — it’s health insurance reform.

But the goals of increasing access to care and increasing Americans’ health go hand in hand. The authors of the law recognized this; the ACA funded billions of dollars into comparative-effectiveness research, for example. Even the White House has made the explicit connection between coverage and care.

“You have turned, Mr. President, the right of every American to have access to decent health care into reality for the first time in American history,” Vice President Biden said five years ago, the day the ACA was signed into law. “Tens of millions of Americans will be a whole lot healthier from this moment on.”

White House spokesperson Josh Earnest also argued this week that the ACA has saved the lives of more than 50,000 Americans by reducing hospital errors and improving the quality of care.

However, it’s been tough to track the direct impact of the law on Americans’ health. Harold Pollack, a health services researcher at the University of Chicago, warned California Healthline in 2014 that we might never know for sure.

The health law “is basically the bumper sticker in this really seismic shift in how health care is delivered,” Pollack said. “And many of the things that are happening [might] have been happening whether or not the ACA would be passed.”

Harvard’s Katherine Baicker suggested last year that “proxy measures” — like if more patients start using blood pressure medication — could eventually suggest a potential improvement in health outcomes

And a few proxy measures are beginning to appear. For example, a new study contrasts states that opted into Medicaid with those that sat out — like a real-world A/B test — and found that diabetes diagnoses in Medicaid expansion states rose by more than 20%.

“Early and aggressive therapy of diabetes has a major impact on long-term complications and on quality of life,” Robert Ratner, chief medical officer for the American Diabetes Association, told NPR’s “Shots” blog.

Looking Ahead

It’s worth noting that there are a few other things the ACA didn’t do: Many of the worst predictions about the law haven’t come true.

A new athenaHealth report released on Wednesday finds the ACA hasn’t overwhelmed doctors, for instance, despite fears of overcrowding. The “job-killing health law” didn’t appear to kill many American jobs after all. Even the fear about the number of canceled plans seems to have been overstated.

But the ACA’s implementation continues to be bumpy, too. This year’s tax filings are proving to be complicated, and potentially financially painful, for many people who signed up for coverage through the ACA’s exchanges. The Supreme Court may rule this summer that subsidies are illegal on HealthCare.gov, a decision that could force millions of Americans to drop coverage. There’s still a clear need to address these and other problems, and reform the reform.

The “rational thing for lawmakers to do now would be to build on [the ACA’s] progress,” according to an unsigned Los Angeles Times editorial this week.

“But improving the act or even fixing its glitches has never been an option because the debate over Obamacare has always been political, not rational.”

Around the nation

Here’s a look at other stories making news on the road to reform.

A ‘private option’ for Georgia? Some Republican leaders in the state — which so far, has refused to expand Medicaid — are pointing to Arkansas’ health reforms as a model, Misty Williams reports for the Atlanta Journal-Constitution.

Hospital pricing, appraised. At Slate, Reihan Salam argues that hospitals’ market power is disproportionately driving health care spending. Austin Frakt, writing at the New York Times, scrutinizes the argument that hospitals must shift costs to private insurers. 

Many health plans still aren’t ACA-compliant. Writing at the Washington Examiner, Paige Winfield Cunningham notes that as many as 30% of the nation’s insurance plans have been “grandfathered” in under the ACA, meaning they don’t have to comply with the law’s minimum-benefit requirements.

Related Topics

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