Uncertainty Surrounds Healthcare Reform on Its First Anniversary

This article first appeared on HCPLive.com.

Wednesday marked the first anniversary of the Affordable Care Act (ACA) being signed into law by President Obama, and one year into the new era of healthcare reform it’s clear that Americans remain divided in their views of the benefits of the law. A poll from the Kaiser Family Foundation found that the public is confused about the provisions of the ACA and the timelines for their implementation, with many people feeling that they lack sufficient information explaining how the ACA will affect them.

According to Kaiser, “Americans like the idea of state flexibility, with the caveat that the plans they offer are of equal quality and cover just as many people, but are opposed to the idea of defunding health reform. The public is still split on repeal, with slightly more wanting to expand the law or leave it as is than wanting it repealed entirely or repealed and replaced.” The poll also found that, depending on how the question is phrased, a majority of respondents wants to repeal the individual insurance mandate. Another poll conducted by Rasmussen Reports shows less support for the ACA, with 53% of likely voters at least “somewhat” in favor of repeal (including 43% who “strongly favor” repeal) and 42% of respondents opposed to repeal (including 27% who are “strongly opposed”).

Opinion on the benefits, impact, and consequences (foreseen and unforeseen) also remains divided with supporters, such as former Congresswoman and current President and CEO of the National Committee to Preserve Social Security and Medicare Barbara Kennelly, claiming among other things that under the ACA the federal government has recovered $4 billion in Medicare fraud, with Medicare itself “stronger than it was before the law was passed,” with better benefits, including more affordable prescription drugs and better coverage for things such as annual wellness visits and diabetes and cancer screening.

In a piece in the Washington Post, Ezra Klein said that the ACA, “once it kicks in fully in 2014, is expected to do four things: provide coverage; remake a small slice of the private insurance market; pay for itself; and try to control costs.” Savings will be achieved through a mix of offsets and cost-control mechanisms, which Klein described as “ambitious attempts to change the way doctors are paid, insurance is bought, and Medicare is reformed” that, if they work, will in the long run “save an enormous amount of money -- much more than the offsets.”

Among these offsets are measures designed to “slow payment increases to providers who participate in Medicare ($240 billion), cut payments to private insurers that participate in Medicare, but cost more than the basic Medicare program does ($140 billion), increase the Medicare tax on high earners ($210 billion), and add a tax on very expensive health-care plans ($20 billion, although much more than that between 2020 and 2029).”

A Prelude to a Two-Tiered System?

Critics of the law point to a variety of potential downsides, running the gamut from the law potentially being unconstitutional to healthcare consumers being left with fewer, more expensive choices when it comes to health insurance, to lower pay for physicians. In a blog on Forbes, Avik Roy claimed that the ACA “will achieve exactly the opposite of its stated goals: patient protection and affordable care,” and offered a rundown of several “unintended consequences” that were in fact entirely predictable.

In particular, Roy pointed to this blog by John Goodman of the National Center for Policy Analysis that predicts “a large migration of patients and doctors, and facilities and services out of the third-party payer system,” accompanied by a concomitant “major increase in concierge doctors, concierge facilities and concierge-type services,” all thanks to the ACA. Goodman noted that healthcare reform was intended to increase the number of patients covered under health insurance, promote the use of electronic health records and other high-tech solutions to enable clinicians to provide “lower cost, higher quality, more transparent care,” increase access to care for all segments of the population, and in general promote the creation of a fairer, more egalitarian healthcare delivery system.

Yet, because of the consequences of the individual mandate, the structure of the planned health insurance exchanges that are scheduled to debut in 2014, the “bizarre system of health insurance subsidies,” the market distortions, and other provisions of the ACA, Goodman said that “the world we are about to enter will be the exact opposite -- a two-tiered system in which access to the best doctors and the best facilities will depend very much on your ability to pay,” a system in which “our more vulnerable populations -- the poor, the disabled and the elderly -- are likely to have less access to care under the new reforms than they have today.”

According to Goodman, the ACA “may indeed cause the transformation of medical practice that the ACA seeks to bring about. But it will not occur because of the guidance Washington gives to providers in the third-party payment system. It will occur because of the competitive pressures that everyone who escapes from that system and practices outside it will face. And it won’t be available to those who need it most.”

Physician support for the ACA reflects the divide among the general public, with many professional associations such as the American Academy of Family Physicians (AAFP) expressing support for the law but vowing to seek reforms that protect patients and physicians. In a news release, the AAFP said that while the ACA has “implemented numerous strategies for improving health care delivery and making more available affordable, high-quality care,” the law must be changed so that payment levels in affected programs cover provider costs. Specifically, the AAFP called for the Medicare physician payment system to be “fundamentally reformed to eliminate the sustainable growth rate (SGR) formula that has required repeated Congressional interventions to prevent steep annual payment cuts that threaten access to services.” The AAFP has also expressed concerns that the ACA "might not accommodate privately owned, small- and medium-sized physician practices.”

Other organizations have also voiced similar concerns over physician payments, burdensome regulatory requirements, confusing statutory language, and the misaligned financial incentives created by the ACA. With those in favor of the law claiming that public support will increase when the meat of the reforms begin taking place in 2014, and opponents predicting further erosion of support once the true negative outcomes become apparent and patients and physicians begin to feel their effects, and stakeholders on all sides of the debate acknowledging the need for additional tweaks and changes to the law, this story is far from over.