4 ways to improve the Affordable Care Act

The fate of the Affordable Care Act (ACA) will be the big issue in the upcoming mid-term congressional elections, with Republicans and their allies continuing to press for repeal, believing that it is a winning issue with voters (or at least the base voters who lean Republican). Opinion polls are not as clear-cut, though. Although more Americans continue to have a less favorable than more favorable view of the law, most oppose outright repeal.

But no matter what the politicians say in the election, the ACA is here to stay, at least as long as President Obama is in the White House and probably much longer than that. Although we don’t have the final enrollment numbers from October 2013 through the first 3 months of 2014, when the first open-enrollment period for the marketplace plans created by the ACA ended, it is likely that total enrollment as of April 15 will fall between 15 and 18 million people, nearly 8 million in the marketplace plans, another 5 to 7 million in Medicaid, and between 1.6 and 3 million young adults on their parents’ plans.

Because of the ACA, tens of millions more Americans have no lifetime or annual limits on coverage, and seniors enrolled in Medicare have better coverage of prescription drugs and preventive services. No one, regardless of health status, can be turned down or charged more by insurers. These enrollment numbers will likely increase over the next several months and years as more states decide to expand their Medicaid programs and as the next wave of marketplace enrollment occurs in fall 2014.

Politicians, regardless of their political leanings, can count. As more voters benefit from the ACA, I see no scenario where Congress will reverse course, even if the Republicans take control of the Senate next year. (And, of course, President Obama would veto any major changes to the ACA.) At some point in the future, but unfortunately not for another election cycle or two, I believe that our politics will shift to a new normal, where the ACA is accepted by both political parties (like Medicare, which itself was initially very controversial, is today), and the debate will shift to how to revise it, not repeal and replace it. I doubt that will happen until the next presidential election in 2016, though.

In the meantime, 4 things could be done to make the ACA better, learning from the experiences, good and bad, in this first year of enrollment.

First, make the enrollment portals work better. The federal enrollment portal, Healthcare.gov, is obviously working much better than it did a few months ago, but it is still a work in progress. And several states running their own marketplaces, including Maryland, Oregon, and Massachusetts, continue to struggle with enrollment software that is minimally working (or in the case of Oregon, not working at all). These all need to be improved by Nov. 1 of this year, when the next enrollment period begins.

Second, make the consumer shopping experience better. It may be years before the enrollment process makes it as easy to select a plan as Amazon.com makes it to shop for products, but there are several things that would make the experience so much better than it was this time around. Provide consumers with real-time access to up-to-date directories of participating physicians and hospitals, so they know which are in or out of the plans they are considering. Make it possible for them and their physicians to review whether a particular prescription drug is in a plan’s formulary. Make it easier to compare the plans based on premiums, deductibles, and co-payments; the benefits offered; and the enrollee’s total premium cost after income-based subsidies are applied.

Third, improve network adequacy standards, ensure greater health plan transparency, and strengthen rights of appeal. The federal government and state regulators should develop clearer standards to set a higher bar on network adequacy, so that patients have greater access to the physicians and hospitals of their choice, are not forced to go long distances to get care, and experience fewer disruptions in continuity of care. Potential enrollees and their physicians should be able to know, and challenge, the criteria used by qualified health plans in determining who is in or out of their networks. Physicians should be able to challenge and appeal de-selection decisions. Patients should have expedited appeals if the medication their physician prescribes for them is not on a plan’s formula, especially in medically urgent situations.

Fourth, improve the Medicaid program. The fact that tens of millions of poor people will have access to Medicaid is a good thing. The most important improvement for this population would be for all of the states that have declined to expand the program to get on board. At the same time, Medicaid is by no means a state-of-the art program. Except for a few pioneering states, Medicaid is not considered to be a hotbed of innovation in payment and delivery. The program’s rules are cumbersome, and its payments to physicians and hospitals are too low. Yet Medicaid already is the single largest coverage program in the United States, and as more join the program, state governors, legislators, Congress, and the Obama administration should find bipartisan approaches to making it less expensive, more efficient, and more accessible to both patients and physicians.

Such improvements are not conducive to the red-hot politics over the ACA’s fate, where everything is shouted in apocalyptic terms designed to scare and motivate voters. But isn’t the purpose of politics to elect people who will do what is best for their constituents? Wouldn’t constituents benefit by making the ACA work better for them?

Many of the improvements discussed here can be made without Congress’ consent, through administrative rule-making, oversight, and state regulation. Congress and the states, though, can make things worse by denying the funds needed to, say, build a better federal enrollment site or by declining to expand Medicaid, not because this would be in the best interests of constituents, but for partisan, ideological, and political reasons.

We have an opportunity to improve the ACA, and the least we can hope is that politicians don’t get in the way.

Bob Doherty is senior vice president, governmental affairs and public policy, American College of Physicians and blogs at The ACP Advocate Blog. This article originally appeared in ACP Internist.

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  • QQQ

    The Los Angeles Times. April 2, 2014

    The Los Angeles Times reported on the study and is the only news outlet so far that has seen the secret Rand study. Moreover, a McKinsey & Co. study says that just 53% of the previously uninsured have paid their first premium and activated their coverage.That would mean that just 1.2 million of those the White House calls “enrollees” are actually paying Obamacare customers who were previously uninsured. Obamacare’s purported purpose was to provide coverage for America’s 48.6 million uninsured people. Based on the Rand study, Obamacare has provided private insurance for only 2.5% of America’s uninsured. The highly unpopular Obamacare program has Democratic strategists and candidates scrambling for cover. One prominent Democratic pollster told Politico that the best thing Democrats can do is change the subject. “The less we’re talking about Obamacare, the better off we are,” said the pollster.

    The latest Associated Press poll shows Obamacare has hit an all-time low approval rating of just 26% . Millions have lost their health insurance. Many more have seen their premiums skyrocket. It’s also being reported that the RAND Corporation has compiled a study that shows the true numbers behind the enrollee claims. They’ve found that only 53 percent of Americans who previously did not have health insurance have
    actually paid for their new plans. In fact, the RAND Corporation’s study shows that only roughly 858,000 Americans who did not have insurance beforehand have gotten it since ObamaCare took affect. They suggest that only 23 percent of enrollees had no insurance before this entire debacle began. Yet we’re told that ObamaCare will provide insurance to everybody. Looks like Obama has another 47 million Americans to go. All that chaos and disruption for having less than a million people covered as prices spiral drastically upwards for everyone.’The debate over repealing this law is over’: Obama boasts 7.1 MILLION have signed up to Obamacare – but study shows just 858,000 newly insured Americans have paid up!

    • DeceasedMD1

      And the problem I believe-correct me if I am wrong-is that Obama is subsidizing private insurance for any losses incurred for awhile post ACA. What a mess.

  • Thomas D Guastavino

    The ACA is not going to work in its present form for one simple reason. Supporters have made the false assumption that care will be available irrespective of what the providers will be reimbursed and what hoops they may have to jump through to get it. If Medicaid, and increasingly Medicare, has not shown this I don’t know what will.

    • Dr. Drake Ramoray

      I for one believe that it isn’t supposed to work, at least not the way you think. The goal of the ACA is to divest health insurance from your employer (not necessarily a bad thing), make practicing independenty as a physician exceedlingly difficult to herd doctors into big conglomerates and corp med, and then the movement to single payer can proceed. Patients will have no love for the insurance companies, neither do doctors. Once physicians income is tied to the wellbeing of hospitals, patient satisfaction surveys, and the whims of their CEO, MBA, manager and the dictats of regional monopolies controlling healthcare, they will not muster any resistance to the coming change. They will be cogs, in the coporate works.

      The problems most frequently cited by non-docs in Medicaid is that doctors won’t see the patients. The problems with the ACA is that some states won’t expand Medicaid etc. You know it’s a mess, I know it’s a mess and we are underpaid but the general public doesn’t know that. It is already being bandied about in Massachussetts and Virginia about seeing Medicare/Medicaid as a condition of state licensure. (No direct pay/concierge medicine unless you want to practice without a medical license). At one time a proposal in Massachussetts suggested using EMR data dredging to insure that physicians were seeing a number of Medicare/Medicaid recipients “consistent with the demand for medical services in their community.” (ie you have to see a certain number of these types of insurances) not just pay lip service to seeing Medicare/Medicaid.

      I for one think the fate of healthcare was sealed by the NFIB vs. Sebelius decision. Single payer is only a matter of time, for when the ACA “fails” and it will “fail.” The scapegoat will be the private insurance companies. The government tried to work with them, but they are just greedy. The only proposed fix will be single payer.

      The real question is if/when will doctors unionize or push for the right to collectively bargain as we move towards that system which pays us less than the money it costs to provide care (Medicaid in many states).

      • DeceasedMD1

        “The scapegoat will be the private insurance companies. The government tried to work with them, but they are just greedy.”

        I so wish you are right Drake. But the same did not apply to the banks. And it’s not just the private insurance companies that are greedy as you know. It’s everywhere you look pretty much within the MIC(Medical Industrial Complex). The MIC is not going to give up on nearly 20% of the GDP. And the gov’t has well, no balls, to stand up for what is right.

        But it is about time to unionize. Our political leaders are pathetic, regulating us to death. Meanwhile the MIC exploits. And of course forget the medical societies. Any ideas of why it is so hard to unionize? Not sure if specialists are as dissatisfied but I suspect many are like Dr. G. (Not a simple question, but all of this is like a nuclear bomb destroying the practice of medicine and i also think the learning experience- fear the new residents will be -think of Stepford Wives. Unionizing sounds like the best solution to me too.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        I agree with everything you said, except the single payer thing. Yes, doctors will be herded into subservience to health systems. Yes, employers will gradually get out of the insurance business, but without increasing wages. People will be sent to the public exchanges to collect government subsidies for increasingly higher premiums and lower benefits. So in essence, employers will be externalizing the cost of health insurance to subsidies, pretty much like Walmart does now to Medicaid.
        Effectively, the government will be paying for most health care costs, but in the most insanely inefficient way, just so it can flow through private insurers so they can take their profits off the top, before it goes to health systems for their share, and whatever is left can go to actual medical care, which includes profits for pharma, devices and technology.
        On second thought though, I guess it is sort of like a single payer…. :-)

      • Patient Kit

        I wish. I’d love to see the US move to a tax-funded single payer system and doctors unionized with good pay and good benefits and free to concentrate on treating patients instead of being constantly sidetracked with how to survive the business-side of medicine. But people keep telling me that will never happen in this country.

    • DeceasedMD1

      You are spot on. Basically no one in politics is listening no matter how obvious and critical. They are there to make sure they get re elected and that seems to be all that matters to them. Case in point, I just discovered, with all the recent mass shootings, that nothing and I mean nothing has been done to help fix the problem, whether you look at it from the broken mental health system perspective or gun laws. Sandy hook seemed to make little impression. Pathetic.

    • Mike Henderson

      It seems reasonable for ACA supporters to assume physicians will just keep taking Medicaid, despite below cost reimbursement and increasing regulation. When in our history have we truly refused to stand up to insurance companies or Medicare? Even as a physician, I think physicians as a group only pay lip service to doing what is in the best interest of patients. I think they view us as paper tigers.

      For example, a local physician of one of the larger medical groups where I live was quoted in the paper in the last few weeks saying that exact thing – (paraphrasing) “No matter how many Medicaid patients there are, we will make sure they are spread around to all physicians.” He was hoping to break even on his medicaid patients.

  • ninguem

    Why on Earth does any internist belong to the American College of Physicians, when it is led by people like this?

    • Dr. Drake Ramoray

      His articles do have a Pravda sort of ring to them don’t they. The ACA was passed with no Republican input, but it doesn’t work because the Republicans are obstructing. I say they make the senior vice-president, governmental affairs and public policy a Cabinet level position and be done with it.

  • John

    Four words: Repeal the whole enchilada.

    • Patient Kit

      All legislation is much easier to modify and amend than it is to get it passed in the first place or repealed. If you think the ACA will be easily repealed, you have no idea what it took to get it passed into law. It needs to be fixed, but I agree with the OP that it isn’t going to be repealed any time soon.

      Therefore, it’s important for patients and doctors to make our voices heard in Washington about what, specifically, is not working for us and how, specifically, we want it changed. I have a lot of issues with the ACA myself but there are enough good things in it that I do not want to see it repealed — unless, of course, we move to a tax-funded single payer system and eliminate the insurance companies completely.

  • John

    ACA as written will never be fully implemented and only parts of the “law” will last. The working American will not tolerate the realities of single payer and what happens in MA or VA with licensing will not happen everywhere.

  • Ava Marie Wensko George

    My four words are: Health Care For All. and my parting shot? SINGLE PAYER NOW….

  • Jennifer Jonsson

    I have Obamacare and it’s fine. I have no subsidies (that is none, zip, zero, nada) because I make too much money. I’m 45 and my premiums are $377 per month for a “silver” plan, which is eminently reasonable. My deductible is the same as I had when I had health insurance through my employer, $2500. Two of my prescriptions are free (free!), doctor’s visits are $35 and specialist visits are $55. It’s a Blue Cross/Blue Shield plan and my doctor was already on it. In other words, it’s really no different from the plan I had from my former employer. I have yet to meet anyone who actually has Obamacare that also hates it and thinks the law should be repealed.

    I do think, though, that prospective customers should be positively encouraged to call their doctors and make sure the doctor subscribes to the plan they’ve picked out. That’s just common sense, but a lot of people buying health insurance don’t think of it.

  • logicaldoc

    “5″ Ways to improve…Add real Malpractice Reform (not “Tort” Reform); the ubiquitous core problem driving Healthcare costs in the first place.