Savannah Bergquist1 and Arthur R. Bartolozzi, MPhil2
1Harvard School of Public Health, Boston, MA 02115, USA
2Harvard Medical School, Boston, MA 02115, USA
*Correspondence: firstname.lastname@example.org; email@example.com
Certain provisions in the ACA are expiring soon, and those expirations will create room for further policy debate. We present three cornerstones of reform in this context that these debates will need to address in order to be viable.
Health care reform is not a discrete event that ended with the passage and implementation of the Affordable Care Act (ACA) in 2010. It is an ongoing process whose success depends upon the sustained involvement of policymakers, providers, patients, and other stakeholders. The provision on increasing Medicaid payments for primary care services encapsulates the decisions and challenges of continuous reform.
Beginning in 2013, the ACA used federal funds to temporarily raise Medicaid primary care payments to Medicare levels. These federally funded rate increases are due to expire at the end of 2014. On average, Medicaid fees were increased by 73%, although the magnitude varies by state (Zuckerman and Goin, 2012). Given the Medicaid expansion stipulated by the ACA and pre-ACA survey results showing only 70% of physicians would accept new patients with Medicaid compared to 96% who accepted new patients (Decker, 2012), increasing primary care provider participation in Medicaid has been viewed as an important step to ensuring the ACA’s success in providing affordable health care. This is important despite counterarguments that Medicaid or uninsured patients receive equal attention at primary care appointments (Bruen et al., 2013). We dissect the intricacies of this argument in “Evidence-Based Policy” below. With PCP participation in mind, Senators Patty Murray (D-WA) and Sherrod Brown (D-OH) introduced a bill to extend the application of the Medicare payment rate floor until 2017. In response to the overall primary care physician shortage, OB/GYNs, nurse-midwives, NPs, and PAs will also be eligible for the payment increases. The bill has been referred to the Senate Committee on Finance; it is uncertain if it will pass in the Senate, and it is also unclear if it will pass in the Republican-controlled House.
The broader turmoil about the future of the ACA obscures some of these important—albeit less controversial—provisions and regulations of the landmark law. The ACA authorizes a variety of demonstration grants, changes to payment systems, and temporary programs that provide opportunities for continued reform without waging major political battles. Regulations are a key step in translating the ACA to changes in health care delivery. Built-in expirations and annual updates could mean these regulatory changes have far-reaching effects. We can maintain a path to improved health outcomes by further prioritizing programs that increase coverage, using data from rapid-cycle evaluations to drive our policy updates and resource allocation decisions, and continuing to balance public program investments and private sector innovations.
Continued health care reform will inevitably involve further political conflict. Authorization and funding for existing programs that increase health insurance coverage should be prioritized. For example, the ACA approved CHIP funding only through September 2015. While there is substantial overlap between CHIP and the children who qualify for coverage through the ACA’s health insurance exchanges, implementation of the exchanges has been significantly complicated. For example, individuals may purchase a health insurance exchange plan using federal subsidies if the cost of participating in their employer’s insurance plans exceeds 9.5% of their income. However, this 9.5% affordability threshold only takes into account the premiums for the individual, not their dependents. This regulatory error has been termed the “family glitch,” and until it and similar problems are resolved in the exchanges, CHIP should continue to be funded, because without it, an estimated 1.9 million children would be without reliable coverage (Alker, 2014). Both funding CHIP and resolving regulatory issues in the exchanges require Congressional action; as long as there is a party split over the ACA, CHIP funding may be more politically feasible because it is not directly associated with the ACA.
The 2015 expiration of CHIP funding also presents an opportunity to streamline payment regulations and to think critically about the future of safety net coverage for children. Senator Jay Rockefeller’s (D-WV) bill to fund CHIP through 2019 offers one vision: along with addressing the problem of premium stacking (wherein a family pays CHIP premiums in addition to exchange plan premiums), the bill expands eligibility and requires states to coordinate transitions between Medicaid, CHIP, and exchange plans. While lawmakers will debate funding and oversight, building on existing programs ensures that fewer Americans slip through without insurance. However, as we move forward with reform, passing what amounts to stop-gap measures should not take the place of negotiating the difficult legislative and regulatory hurdles necessary to streamline our health care payment system.
Expanding safety net coverage in a cost-efficient way requires expanding access to primary care and preventative health services. However, it is not clear that increasing Medicaid primary care payments increases provider participation. Neither CMS nor State Medicaid offices have collected data on whether or not the payment increases are in fact attracting more primary care providers to Medicaid (Galewitz, 2014). While funding is important, access is the goal. Perhaps “Medicaid” carries an unshakeable stigma of unreliability for physicians or, in the context of expansion, seems like a federal overreach. A study from Washington State’s 2011 survey of primary care professionals also highlighted administrative burden, patient complexity, and referral refusal as additional concerns (Long, 2013). Whatever the perception, policy informing continued changes cannot be drafted appropriately without hard data addressing some of the concerns beyond reimbursement.
Data-driven policy is also essential for reducing cost growth. Medicare Advantage payments are slated for a gradual reduction over 10 years, which the CBO estimates will save $136 billion. Although Medicare Advantage has traditionally been viewed as an unsatisfactory policy (i.e., expensive and lacking in quality gains), a group at Harvard found that policy changes to Medicare Advantage from the mid-2000s have reduced adverse selection problems (Newhouse and McGuire, 2014). Prior to the 2003 Medicare Modernization Act, enrollees were unable to switch out of restricted MA plan networks. This resulted in older, sicker, risk-averse enrollees staying in traditional Medicare—a hypothesis confirmed by a 15% mortality gap between traditional Medicare and MA (Medicare Payment Advisory Commission, 2010). In more recent briefings to Congress, MedPAC reports that CMS does not have sufficient access to claims data from MA plans in order to assess comparative mortality (Medicare Payment Advisory Commission, 2014). Given these findings and the large changes to Medicare reimbursement under the ACA—including the introduction of accountable care organizations (ACOs)—future evaluative work comparing Medicare Advantage, traditional Medicare, and ACOs will be essential as these programs come up for re-evaluation.
It is important to advocate for some caution alongside a push for data-driven policy. We should be aware data from newly implemented programs may not tell the entire story and that these data can be abused or misinterpreted to advance a given agenda. There is a necessary lag period as new programs start when appropriate assessment might not be feasible; providers, researchers, and policymakers must work together to balance the need for rapid evaluations and allowing enough time to gauge impact.
Public and Private Interdependence
Publicly funded programs (e.g., Medicare and Medicaid) and the private sector have complementary roles to play in creating and sustaining the ACA’s payment and care delivery goals. Developing ACOs provides an example of how the public and private sectors can work in tandem. The goal of the federal ACO Shared Savings Program is to get providers to cooperate in assuming responsibility for the total cost and quality of a defined set of their Medicare fee-for-service patients. The Shared Savings Program has been key to getting less experienced provider groups involved in payment reform, and private insurer adoption of the model will be necessary to sustain the transition to value-based payment supported by the Shared Savings Program. While the majority of Shared Savings Program participants are only eligible for shared savings, early ACOs with private contracts appear to be more comfortable bearing downside risk for shared losses than public participants (Lewis et al., 2014).
This private sector buy-in is a boon to advocates for accountable care models. In addition to allowing provider groups to gain experience with managing risk, Shared Savings Program contracts are a relatively safe vehicle for testing private sector innovations such as Walgreen’s ACOs embedding pharmacists in primary care teams to improve medication management. Interesting evolutions of the ACO model are appearing in private contracts, as well: Florida Blue and the Moffitt Cancer Center have partnered to form a cancer-specific ACO. However, it is unclear whether this will lead to disproportionate market share and antitrust issues commensurate with the Partners expansions in Massachusetts (Farragher, 2014). A recent review of ACOs argues for size limits and incentive structures beyond what current groups practice. It suggests that ACOs cannot be more efficient than current payment models if they do not follow these prescriptions (Frandsen and Rebitzer, 2014). These reform mechanisms therefore must be monitored closely to prevent unintended consequences such as the creation and exploitation of loopholes around competition laws.
Reform is not stagnant. It relies on changes in public attitude, personal choices, and unifying legislation. “Health outcomes,” however, is necessarily longitudinal, so no claims about the current law’s impact can be validated yet outside the framework of coverage and access (Blumenthal and Collins, 2014). To maximally improve our health care system over time, the practices we advocate for here—universal access, evidence-based policy, and public-private partnerships—should be routinely incorporated in both academic and political processes.
Alker, J. 2014. What Would Happen if CHIP Went Away? Our Research Suggests Kids (for now) Would be Significantly Worse Off. Accessed October 24, 2014.
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Bruen, B.K., Ku, L., Lu, X., and Shin, P. (2013). No evidence that primary care physicians offer less care to Medicaid, community health center, or uninsured patients. Health Aff. (Millwood)32, 1624–1630. 10.1377/hlthaff.2012.1300.
Decker, S.L. (2012). In 2011 nearly one-third of physicians said they would not accept new Medicaid patients, but rising fees may help. Health Aff. (Millwood) 31, 1673–1679.
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Galewitz, P., 2014. 6 States extending Medicaid pay raise next year to primary care doctors. Kais. Health News.
Lewis, V.A., Colla, C.H., Schpero, W.L., Shortell, S.M., and Fisher, E.S. (2014). ACO contracting with private and public payers: a baseline comparative analysis. Am. J. Manag. Care 20, 1008–1014.
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Medicare Payment Advisory Commission, 2010. Report to the Congress: Aligning Incentives in Medicare.
Medicare Payment Advisory Commission, 2014. Report to the Congress: Medicare and the Health Care Delivery System.
Newhouse, J.P., and McGuire, T.G. (2014). How successful is Medicare Advantage? Milbank Q.92, 351–394.
Zuckerman, S. and Goin, D, 2012. How much will Medicaid physician fees for primary care rise in 2013? Evidence from a 2012 survey of Medicaid physician fees. Urban Inst. Kais. Fam. Found. Issue Paper #8398.