The Affordable Care Act: Extending Coverage to Millions of Americans

2015 Breast Cancer Symposium

A closer look at the $2.7 trillion spent on healthcare in the United States in 2011 reveals a system of extreme imbalances, characterized by excessive consumption of care on the one hand and lack of access to necessary care on the other. The Affordable Care Act (ACA), outlined by Otis Brawley, MD, at the 2015 Breast Cancer Symposium, has helped to restore a semblance of balance to this system, but great strides still need to be made to decrease waste and improve the overall health of Americans.

“The ACA is undoubtedly hard for doctors, but it’s generally a positive for patients,” said Brawley, Chief Medical and Scientific Officer at the American Cancer Society and Professor of Hematology, Medical Oncology, Medicine, and Epidemiology at Emory University in Atlanta, GA. “There is lack of coverage for patients with incomes below 100% of poverty level, which is a huge concern, but there has been expansion of coverage for preventive care and implementation of clinical trial coverage provisions for everybody, except those insured on Medicaid. That is a positive, but we would like to expand it further.”

As Brawley explained, a trillion, so far removed from quotidian values, can be a tricky concept to grasp. In 2011, the year Americans spent $2.7 trillion on healthcare, $1.1 trillion was spent on food. Of every dollar of the US gross domestic product (GDP), 17.9 cents was spent on healthcare.

“The number is so big,” said Brawley, “that if American healthcare were its own economy, it would be the 5th largest economy in the world.”

“Put another way,” he added, “we spent more money on healthcare in the US than was spent on everything in France in 2011. It’s a huge sum.”

Despite this massive investment, however, outcomes have been less than impressive. Infant mortality, white male life expectancy, and age-adjusted mortality rates for the United States are middling in comparison to Western European countries that spend only 8% to 9% of their GDP on healthcare.

ACA Legislation

More payment reform than health insurance reform, said Brawley, the ACA does not effectively address many of the aforementioned issues of cost. That’s not to say, however, that it hasn’t positively affected patients.

According to Brawley, the ACA:

• Brings insurance coverage to most patients (but not all)
• Gives premium and cost-sharing subsidies
• Provides screening services without cost-sharing
• Offers clinical trial protections for people on private insurance and insurance other than Medicaid.

The ACA poses distinct challenges for providers, though, including Medicare Value-Based Modifiers and penalties for hospital readmissions. There’s also an Independent Payment Advisory Board.

“Things are going to get a lot more difficult for those who provide care,” Brawley cautioned.

In the 1300-page legislation, the word quality appears 483 times. Despite the verbiage, however, Brawley indicated that the ACA does little to bring about actual quality in care.

“All employers who have at least 50 full-time employees are required to provide coverage for full-time employees or pay a penalty,” he said. “Many employers are choosing to pay a penalty, encouraging their employees to buy insurance from the exchanges instead.”

In 2014, Congress passed legislation to expand investment in quality and put a quality/cost grid into place, increasing penalties to doctors for not practicing medicine according to certain quality metrics and offering a bonus (up to 27%) for those who do.

“In 2013, under the old rule, two-thirds of hospitals received penalties of $280 million (0.3% of operating revenue),” said Brawley. “Hospitals taking care of the poorest Americans were disproportionately penalized compared to those taking care of the wealthiest patients.”

The average penalty, he noted, was 0.45% for the poorest hospitals versus 0.21% for wealthier hospitals. Additionally, 41% of wealthier hospitals received no penalty at all, while only 14% of the poorest hospitals were exempted.

“We should consider assessing and applying quality adjustments within hospital cohorts based on patient income and education,” he said.

These adjustments notwithstanding, the ACA has done much to close the coverage gap. Under the ACA, the Congressional Budget Office estimated that 29 million Americans will be uninsured in 2018. A sobering thought, Brawley concluded, but it could be worse. “If not for the ACA,” he said, “there would be 56 million uninsured Americans in 2018.”

Where is this additional coverage coming from? In short: Medicaid.

“The majority of individuals who become insured have done so because of the expansion of Medicaid,” said Brawley. “It’s not private insurers, and it’s not employer-based insurance; it’s Medicaid.”

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