THCB

Five Things Obamacare Got Right-and What Experts Would Fix

It was one of the most notorious quotes that emerged from the battle over the Affordable Care Act.

We have to pass the bill so you can find out what is in it. – House Speaker Nancy Pelosi, March 9, 2010.

The line was taken out-of-context, as Pelosi’s office has continued to protest. But more than three years after her quote — and nearly three years after the ACA passed Congress — Pelosi’s accidental gaffe seems pretty apropos.

The law continues to delight supporters with what they see as positive surprises; for example, some backers say Obamacare deserves credit for the unexpected slowdown in national health spending. But critics warn that the law’s perverse effects on premiums are just beginning to be felt.

And there still are “vast parts of the bill you never hear about,” notes Timothy Jost, a law professor at Washington & Lee. “I wonder if they’re [even] being implemented.”

Jost and a half-dozen other health policy experts spoke with me, ahead of Obamacare’s third birthday on Saturday, to discuss how the law’s been implemented and what lawmakers could have done better.

Below, you’ll find a selection of their comments, grouped around five of the ACA’s accomplishments and five of the law’s biggest drawbacks.

And keep in mind: While hindsight may normally be 20/20, today it’s 2013.

What the Law Got Right

It expanded health coverage — and maybe more than you think. While many observers tend to focus on the coverage provisions that take effect next year, several experts noted that the ACA’s effects on increasing access to insurance have been near immediate.

“We already have hundreds of thousands of Californians now covered under new options that didn’t exist before the Affordable Care Act, from PCIP to LIHPs to the young adults on their parents’ coverage,” according to Anthony Wright, the executive director of Health Access.

Millions of patients now get no-cost preventive care. The number of patients receiving free services like a mammogram, flu shot or annual wellness visit “has dramatically expanded,” Jost notes. He points to a new HHS report, which found that more than 100 million Americans received no-cost preventive care in the last two years thanks to the law.

Providers are innovating on care delivery. The ACA contains direct funding for Medicare accountable care organizations and other coordinated-care efforts, but the trickle-down effects beyond government-led reforms have been incredibly positive, experts say.

“The momentum that the law provides around the move toward more integrated care is already playing out in positive ways in the marketplace,” according to Micah Weinberg of the Bay Area Council. “It’s not that the Medicare shared savings program itself is going to be the solution,” he adds, but the law has spurred providers to take on new risk. For example, California’s Sutter Health is partnering with United Healthcare and physicians in the East Bay area to produce a competitively priced product for large businesses. The ACA “helpfully moves us in a direction that I’m not sure we would’ve gone in the first place,” Weinberg adds.

Mental health services received a huge boost. The law “is the most important change to [mental health/substance abuse] policies in many years,” says Harold Pollack, a public policy professor at the University of Chicago. Writing in the current issue of Washington Monthly, Pollack pulls out one example: Hundreds of thousands of mentally ill homeless people will gain access to regular health care, thanks to Obamacare.

“This is just a huge improvement for mental and behavioral health services in the United States,” according to Pollack.

The model of risk selection. The law deserves credit for eliminating health status underwriting and denying coverage for pre-existing conditions, Jost points out.

“ACA has changed the basic business model of individual and small-group insurance,” Pollack agrees. “This will present many challenges. But the old business model for many firms based on risk selection has been substantially reformed.”

What the Law Got Wrong

It’s written in a very confusing way. Overwhelmingly, experts pointed to the challenges that emerged from the rushed process to finalize the bill — confusing statues and loopholes that are still making trouble for regulators.

“If we were to run the clock back, one would hope that in conference committee we could have ended up with simpler solutions,” says Weinberg.
A single Massachusetts lawmaker deserves a share of the blame, one expert grumbles.

“I wish Martha Coakley were a better politician, so that the bill could have been professionally scrubbed in conference committee before final passage,” Pollack says.

Implementation took way too long. Even Don Berwick, the former head of CMS, thinks that the ACA’s staggered implementation is regrettable.

In response to my question at the Association of Health Journalists’ conference last week, Berwick argued that the law should have moved more quickly to implement health insurance exchanges and close the Medicare prescription drug benefit donut hole.

Some of those delays were politically motivated: Pushing off the most expensive provisions helped keep the Congressional Budget Office’s score of the ACA down. And of course, major reforms, like staffing up and building out the infrastructure for health insurance exchanges, do take time and funds.

But in hindsight, “I don’t know that you needed four years,” to implement Obamacare,” says Josh Barro, lead writer of Bloomberg View’s blog “The Ticker.”

“Maybe you could’ve done it in two.”

It passed the buck to get necessary bucks. Obamacare’s efforts to raise revenue “were very bad,” Barro argues, with complicated tax provisions and too much pressure on high earners.

“Basically, [the measures] were designed to do as much economic damage as possible for each dollar of new revenue raised,” he adds.

And there’s a deeper issue behind the law’s structure, Barro suggests.

“It’s pernicious to tell people that we’re going to expand the size of the federal government, and don’t worry — someone else is going to pay for it.”

It included too much complexity for businesses. Many employers are still puzzling over how the ACA will affect their operations and trying to figure out whether they’ll keep or drop health coverage when new provisions begin to take effect next year.

“It turns out that the small business tax credit is really complicated,” says Weinberg. “And the employer responsibility requirement is mind-bendingly complicated.”

It opened the door to provider collusion. Berwick noted that the ACA’s push to integrate care also set up an opportunity for providers to take advantage of the law for their own benefit: By using their expanded market power to push for higher prices. Perhaps the law could have been better structured to protect against that outcome, he suggests.

Looking at the Next Three Years — and Beyond

While President Obama’s re-election cinched the ACA’s survival, a tremendous amount of effort still lies ahead to ensure that the law reaches its potential.

“The people who care about the law need to be even more clear-eyed about making it work,” says Weinberg.

But it’s important not to be too hard on Obamacare, Pollack warns.

“It’s miraculous that the bill passed at all, given all the obstacles,” he adds.

“Our difficult legislative process gives you at most one shot to enact a huge reform like this. It’s hardly surprising that this isn’t a context that promotes the most technically proficient policies.”

And judging the ACA on its third birthday is taking a snapshot of a law that’s still relatively immature.

“The real triumphs will be in 2014, with the major expansions and benefits slated,” according to Wright. But “as with the triumphs, it’s premature to have a complete understanding of the drawbacks … the main law has yet to be implemented.”

Obamacare “was the first battle of a very long war — a very, very bitterly fought war,” Jost notes, with states now poised to pick up the fight.

“But don’t forget how far we’ve come in three years, doing the work of implementation.”

Dan Diamond (@ddiamond) is Managing Editor of the Daily Briefing, a CaliforniaHealthline columnist, and a Forbes contributor. This post originally appeared at CaliforniaHealthline.org.

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  26. You don’t have to continue to suffer with high insurance costs due to pre-existing conditions. If you get a Discount Health Plan (which will cover this and save you money), you can get the treatment you need!
    There are far too many people suffering because of what insurance WON’T cover! And yes, Obamacare will be expensive depending on how much you make.

  27. I am a healthcare professional. According to my patients ‘affordability’ of healthcare is the major concern. I have attempted to read the Obamacare legislation and when I do the content makes my head dizzy. I have a bad feeling about this legislation. I do not see anything that address affordability at all.

  28. First off it is my opinion that we have the best health care system on the planet! I would not consider going to any other country for treatment. So is the problem with the health care system or in how we as a culture pay for the services? I believe Obama Care is an unsustainable shell game shifting funds from one account to another to promote the feel good notion that everyone in the US will be covered by health insurance. Leave it to the Government to take the most drastic and costly approach to the health care issue. I wonder what would happen if the average american put as much time into understanding the available health insurance options as they put into say keeping up with facebook. I found a better way without any government intervention – if you care to read about it here is a link to my story-
    http://tinyurl.com/br845kc
    Thanks,
    Jim

  29. Great valuable and deep analysis… Thanks for helping me to understand more thoroughly the obamacare and it’s implications….

  30. What the hell is a “real time video”?
    This doesn’t pass the smell test.

    Yo, Matthew, comments monitor, somebody….
    I’m just an old crank, but I don’t think this needs to remain published here.

  31. I don’t want more access to insurance. I want access to affordable health care. Insurance is a big reason why health care is not affordable. ACA puts too much credence in the health care industry in its approach.

  32. Theresa, as someone in a similar position (61, pre-existing cond.) and having a lower income than I had 5 years ago by 67%, I am concerned about the so-called assistance to help pay the required insurance premiums through tax breaks under ACA. That’s not going to help me month-by-month when the premiums are due. I too, put off getting symptoms checked because of the out-of-pocket expense. Too bad Medicare doesn’t kick in at 55.

  33. I do not agree with TB or John.

    Some people will do just about anything to save a lot of money, wise or not.

    But health care does not exist in all price ranges. It is a big problem.

  34. “Why are there no health plans that advertise lower premiums because they ship you to India or Mexico for non-emergency surgery?” <<— because no one wants to go to India or Mexico for their health care if they don't have to. How would leaving the country be a virtue?

  35. What John says about insurers not caring about costs rings very true.

    And it is painful.

    The theory behind Clinton Care — i.e. managed competition — was that insurers would lead the way in cost control as a way to offer lower premiums…..this would make a social virtue out of their greed to grab market share.

    And it made some sense in theory. An insurance plan that could say “Our premiums are lower because we use less expensive hospitals” should in theory find some customers. And maybe even a strategically important number of customers.

    But it has never happened. Certainly there was pushback from doctors, who saw potential defects of care in those less expensive hospitals……..and there was much negative publicity about HMO’s denying both valid and invalid claims.

    But the amount of money is so enormous in health insurance, that it seems like some competition shoulld have muddled through. Why are there no health plans that advertise lower premiums because they ship you to India or Mexico for non-emergency surgery?

  36. You have my vote.
    All that bitching about the mandate
    My thinking from the start has been that the opposite of a “mandate” is (wait for it…) an option.

  37. do you think the ACA deserves credit for holding health spending down?

    Opinions are mixed. I think it’s a combination of factors including,,,

    ►the bad economy (discretionary doctor visits are no longer affordable for many)
    ►job losses = insurance loss (COBRA is a joke — your premiums double exactly when your income vanishes),
    ►growth of Medicare Advantage (a fourth to a third of Medicare beneficiaries now have MA, which is private sector insurance kidnapping them from original Medicare — get ready for Managed Care 2.0)
    ►medical pros, both physicians and support services, are moving from small practices to hospitals or other groups aiming to become ACOs as defined by ACA,
    ►growth of concierge practices which will ultimately be more cost effective as their bills begin to find a realistic place in the actual health care market (see Dr. Lambert’s story here at THCB and others),
    ►a sea change in the whole health care universe as everybody braces for what Donald Rumsfeld termed the “unknown unknowns” of Obamacare.

    In short, no, I don’t think ACA deserves credit directly. But the threat of change is all it took to start deflating one of the biggest bubbles of our bubble economy.

    Think of it as a run on the banks (not a far-fetched idea, you know, if you read much about the EZ, Cyprus, etc.) which gets everybody squirming who has anything to do with banks — especially those with mega-fortunes that are NOT insured above set amounts.

    When I say “bubble economy” I’m referring to the various economic blisters that form as returns on “investment” become more important than the product or service in which the so-called investment is made. It’s easiest to see with education (from pre-school through college), prisons, out-sourced civic utilities and of course anything to do with the still-toxic real-estate and banking sectors.

    The medical care bubble has been swelling since the introduction of Blue Cross/ Blue Shield when medical professionals secured a Faustian bargain with politicians that their bills would never be questioned — whatever providers put on the bill must be honored as the cost. (The insurance people who manage risk but not costs, care little about the amounts, so they have no problem with whatever the amounts may be. In fact, the more money they handle, the more they make.)

    But I digress. Excuse my blabbering…
    I’m prone to drone on.
    http://qote.me/bohhSE

  38. There is still a painful disconnect between overall health care costs versus what an individual is charged for health insurance.

    I have no affection for insurance companies, but if a new enrollee is likely to generate $5000 in health care costs, the insurance company msut charge them $5000 plus costs or go broke.

    That is why health insurance premiums can skyrocket even if overall costs are going down.

    The solution is a public option — again!

  39. In case anybody here is still interested, here is a link to yet another Ezra Klein collection of charts and bullet points having to do with the current state of affairs with ACA.

    http://www.washingtonpost.com/blogs/wonkblog/wp/2013/03/23/obamacares-five-biggest-challenges/

    Here is #5

    Controlling health-care costs. It’s one thing to hand out health-insurance cards; that’s relatively easy. It’s quite another to ensure that an insurance card guarantees access to affordable health care.
    Right now, that’s looking surprisingly possible: Health-care costs have grown at abnormally low rates for three years running. Some see this as a permanent trend in health-care spending, while others argue that it’s a temporary side effect of the recession.
    Federal forecasters do expect a big bump in health-care spending next year, when millions of Americans enroll in subsidized health plans. But going forward, a big question looms about whether the Affordable Care Act can do more than expand coverage — whether it can also control costs.
    The law contains a number of experiments designed to drive down health costs, such as Accountable Care Organizations. The whole idea is to move the system away from paying for volume and toward paying for value. We still don’t know whether that will happen. But it’s fair to say that reducing the cost of health care will make it easier to expand coverage.

  40. Re: delayed implementation, that was as much the Democrats’ decision as anything else.

    Waiting until 2014 to implement Medicaid coverage expansion and launch the exchanges was partly because of the time it takes to get such huge initiatives up and running.

    But those delays also helped keep the cost of the law below $1 trillion over the ten-year window that CBO scored — a key component in getting conservative Dems to sign on in Congress.

  41. Good points from John Ballard……all natikonal health care systems have perpetual disputes about hgh costs, and some systems are more inflationary than America’s. Our system does have financial brutality towards individuals, versus other systems which have more waiting lists and denial of care. There is no magic bullet.

    I liked the example of chemo vs palliative care. In my writing I offer a different solution — that we may about the same for chemo that we do for palliative care. If palliative care costs $2500 for the hours of counseling involved, then pay $2500 for chemo. Of course this means that prices must be regulated for drugs which have no substitutes.

    If we pay Dr Dean Ornish $3000 to give diet therapy to sufferers of heart disease, then we would pay $3000 for heart surgery.

    Bob Hertz, The Health Care Crusade

  42. Don’t you hate when you have to do that?
    Mr. Kleinke, you’re too subtle for your own good making the point.

    Anyway, though I considered myself a single-payer advocate before the debate I changed my mind for two reasons. First is the potential for rationing. Maggie Mahar says it best:

    Finally, I worry about single-payer being the only game in town during periods of time when Washington is ruled by conservatives–especially conservatives who distrust science.
    .
    One reason palliative care doctors and teams are so poorly paid by Medicare s because many in Congress–and in the administration– object to the idea of Not “doing everything possible.” They will pay a fortune for chemo that will give the average patient an extra 3 weeks of poor-quality life, but will pay very little for a palliative care team willing and trained to spend hours with patients and their families, explaining their options, and letting the patient make the choice

    Second is the simple reality that the delivery of health care around the world varies so much from one country to the next that none is a replica of any other. As a result I see no way that the system that has evolved in America will ever look anything like that of any other country anyway, whether it be a model of national monopoly or some Libertarian, dog-eat-dog construct that so many Conservatives appear to have in mind.

    Our own system has an array of delivery systems from totally government owned and operated systems (VA hospitals, armed forces medical care) to totally free-market models (Kaiser, Mayo, etc.) to hybrids (Medicare, Medicaid, community clinics) and insurance managed HMOs and other variants of managed care.

    There is no way, either politically or culturally, to stuff all that poop back into the elephant. It’s all here to stay. Thank you, Paul Starr (in case anyone wants to read the gory details).

    Comes now PPACA, Rube Goldberg it may be, and that will be the wobbly superstructure for whatever the hell the next metamorphosis will reveal…

  43. I always listen to Mr Kleinke, but I cannot follow him when he suggests (I think in all seriousness) that the ACA subsidies will lead to single payer.

    Can he or anyone else show me how this will happen?

    I am not attacking the thesis, I just cannot grasp it

    If the subsidies are unworkable, I think America just abandons the subsidies, and federal dollars flow where they flow now, into Medicare and Medicaid.

    The working man and woman who does not have a big generous employer or a strong union keeps on getting shafted.

    Let me know if something different will happen.

  44. Actually, the truly evil section of Obamacare are the provisions between page 2400 and 2700 – the real stealth part of the law that exists for one about a third of the law’s most informed opponents. That’s the section with all the steps in the three-year glidepath from the subsidizing of tens of millions of new customers as they enter the commercial health insurance industry, to the single-payer government-owner insurance company that will inevitably result.

  45. Pick a page of PPACA. Any page from page 907 up to 2,700…

    Of the 906 pages in the actual law.

  46. Just pick a date when you believe PPACA will result in more people being covered and costs will be more affordable. Any date.

  47. Wake up, Bobby – the “Dismantle the System” clause is on page 1,938 of the PPACA – tucked in between the requirement that all Americans have chips implanted in them, and the death panel specifications. It includes that odd provision that physicians count off by one-and-twos, with the twos leaving practice so the ones will be grateful that all they have to do is focus on complying with all the intrusions in the physician-patient relationship spelled out in the final couple hundred pages. (The mandatory ultrasound laws, well, they left those out, so the Republicans are making sure that the states pass THOSE laws.)

  48. It’s a violation of protocol to feed trolls, but I have to say this.

    Whoever you are, if you imagine we are discussing “the best health care in the world” you are revealing an embarrassing depth of ignorance and have a lot of homework to do. This post and these comments represent some of the best informed of health care experts anywhere.

    Incidentally, a growing number of physicians are slowly but sure getting with the program.
    http://www.fiercehealthcare.com/story/more-docs-accept-reform-law-public-remains-ill-informed/2013-03-21?fb_action_ids=10200940886305266&fb_action_types=og.likes&fb_source=aggregation&fb_aggregation_id=288381481237582

  49. “after decades of the system grinding away and spitting out tens of millions more without access to any insurance.”

    Truth is…in 2010, there were significantly less than 10 million without access to any insurance. There are these little laws called Medicare, Medicaid, chips, HIPPA, and COBRA that reduced the numbers of people with no access (individuals-legal citizens, with pre-existing conditions (PEC) that rose to the level of individual carriers declining them). I have seen estimates as low as 3 million. Sure, there are more than 10 million without insurance, but most are due to choice (many times the choice was to not apply before the PEC), priorities, laziness, or in limited cases declinations or actual affordability (whatever that means). And by the way, all of these have access to care.

    So, let’s proceed to dismantle the best health system in the world for 315 million people under the guise of promised affordable access to care (not insurance) for these 3 million or so people. Let’s erode the foundation of system serving 300 million people to supposedly help the 3 million.

    At what point in the future should we conclude that fewer people being insured and care being less affordable means this work-in-progress is a failure? 3 years after it passed? 5 years after it passed? 10 years after it past? You choose any of these dates and I bet there are fewer people covered than in 2010 and the cost will be higher including inflation.

    Let’s pick a date Mr. Kleinke.

  50. Wow – a level-headed analysis. Good summary. Obamacare is a work-in-progress, a rough draft, a platform. But it’s a start, after decades of the system grinding away and spitting out tens of millions more without access to any insurance. Warts and all, a giant step forward.

  51. Nice review… Obama had done something which are some what good and some what bad. Good one you categorized this in your own way. Love to see more from you.

  52. The achievements of ACA are real, but the Small Business Tax Credit is not one of the achievements.

    It is puny and stingy and really embarassing, once you read it in detail.

    The average wage must be less than $25,000 to get full credits (which guarantees a low rate of employee participation in most such companies);

    the rules of what an employer must pay toward premiums are shifting and confusing;

    and most numbing of all, the business must make enough money to pay income taxes.

    Funding health policy through tax credits is always inferior to straightforward social insurance. Look at the history of long-term care for confirmation.

    Congress likes tax credits because they are easier to pass than straightforward tax increases for a program like Medicare. Shame on Congress.

    Bob Hertz, The Health Care Crusade

  53. Looks like a realistic assessment to me, too.
    It would be great to have had a faster roll-out but something tells me an army of lobbyists were playing hardball to delay the inevitable as long as possible. (Heck, the idea of “repealing Obamacare” was still a part of the opposition during the election. Still is, in fact, for many looking ahead to 2014 midterms. The meme is as durable as the birther swill, some of which I came across again this week, still being brewed in parts of Arizona.)

    For me the most regrettable development was that Dr. Berwick’s appointment to head CMS was torpedoed, although the man is influential enough that he may be as effective elsewhere as he might have been tethered waist-deep in a political cesspool.

    I will feel much better after we see the exchanges and find out how (or whether) the private sector will embrace them constructively.

  54. As someone who is uninsured, I was all for the Affordable Health Act. But it seems I won’t be helped until next year, when the next batch of laws take effect. Right now because of preexisting conditions, I am stuck with my state’s (Georgia) very expensive PCIP insurance, which I can’t afford. It costs between $477 and $633 a month. (I am 58, if I were younger, it would cost less.) So my health continues to deteriorate, and I worry how I”m going to make it one more year without health care.

  55. I find this summary PPACA right & wrong assessment pretty spot-on. I read every draft as the ACA moved through Congress and then downloaded and read all of the Not-2,700 pages (906 actually) of the enrolled law.

    There IS a ton of grey area crap in it that will surely lead to mischief and adverse unintended consequences.

    One nitpick:

    “Millions of patients now get no-cost preventive care. The number of patients receiving free services like a mammogram, flu shot or annual wellness visit “has dramatically expanded,” Jost notes. He points to a new HHS report, which found that more than 100 million Americans received no-cost preventive care in the last two years thanks to the law.”

    “No cost”? Those are still costs to SOMEONE. They didn’t simply disappear — (100 million people) x (average expense of those services) is a LOT of money. Go ahead: hang a few numbers on it. E-Z math.

    Whether it’ll net out positively by reducing higher costs down the line is at this point still pretty speculative.

    Hope is Dope, I guess.

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