Stuart M. Butler

The Future of the Affordable Care Act: Reassessment and Revision

In this issue of JAMA, President Barack Obama describes many of the features and highlights the results of the Affordable Care Act (ACA).1 Aligning federal payments more with demonstrated value and encouraging a move away from a feefor-service model to managed care has helped reinforce or change the type of reimbursement patterns in the private sector. Allowing young adults to remain on their parents’ insurance plan and curbing preexisting condition exclusions addressed significant problems. Creating exchanges was a key step toward allowing US residents to keep the health coverage they want as they move from job to job. Moreover, significantly reducing the number of uninsured households has brought improved care and a measure of financial security to millions of Americans. However, in looking ahead and thinking about next steps, it is also important to recognize some troubling trends in the ACA that the president has not adequately discussed. For example, the ACA might be more appropriately labeled the “Medicaid Expansion Act.” Although the Congressional Budget Office (CBO) confirmed in March 2016 that there has been a large reduction in the number of uninsured individuals, the sources of coverage are significantly different from its expectations when the law was in the process of enactment.2 Medicaid and the Children’s Health Insurance Program (CHIP) will cover an estimated 17 million more people in 2016 than the CBO’s earlier assessment. On the other hand, enrollment in the ACA exchanges has been disappointing, with an estimated 10 million fewer people enrolled compared with earlier projections. Last year, Department of Health and Human Services Secretary Sylvia Burwell announced a sharply reduced goal for growth in exchange coverage in 2016: just 1.3 million compared with much higher earlier projections.3 Moreover, the CBO now estimates that over the next 10 years, as the population increases, the number of people with coverage will expand only modestly, and the proportion of individuals uninsured will cease to decline.2 A cause of the disappointing trend in exchange enrollment and the strong Medicaid growth is that the premiums and out-of-pocket exposure make exchange plans unattractive to many US residents. With subsidies focused on people with incomes near the poverty line, many middle class and modestincome households find they face substantial and uncertain costs if they enroll in exchange plans. Those choosing bronze plans to keep premiums low essentially have only catastrophic coverage. While that is an improvement over being uninsured, for many it is coverage in name only. For many households, the president’s promise of affordable coverage rings hollow and has not been realized. The president is also unduly sanguine about the future of health care costs. Financing of Medicare has benefited from a slowdown in the increase in health costs. But this trend preceded enactment of the ACA, and many analysts are uncertain about the cause and continuation of the slowdown in the growth of health care costs, attributing much of the moderation to the Great Recession.4,5 The president could be correct that the ACA will slow the growth of per capita health spending, but the CBO and others expect spending to increase more rapidly in the future.6 In addition, the political future of the excise tax on expensive health plans offered through the Editorial page 492

A Federalist Approach To Health Reform: The Worst Way, Except For All The Others

Support for state action should be part of any strategy to expand health insurance coverage. Decades-long political deadlock in Washington has frustrated national efforts to expand coverage. Some states have already undertaken to do this; others show a determination to do so. Regulatory and legislative flexibility would trigger widespread state action. Whether one thinks that ensuring coverage requires a unified national approach or that diverse conditions require different methods in different states, the likelihood of progress will be advanced if states test out various ways to expand coverage. We describe a practical way by which the federal government can promote state action to expand health insurance coverage.

Assuring Affordable Health Care for All Americans

The United States spends over 11 percent of its gross national product on health care. That translates to more than

Repeal and Replace Obamacare: What Could It Mean?

2,000 per person each year— higher than the per capita GNP of many countries.1,2 Yet, although the U.S. spends far more than any other country on health care, there are gaping holes in coverage, and the costs of health care services are subject to runaway inflation. As many as 37 million Americans lack adequate insurance against health care costs3, and many others who have insurance still dread the financial impad of a serious disease.

Risking big changes with small reforms.

onald Trump’s pledge to “repeal and replace Obamacare” was one of his biggest crowd pleasers. It’s been noted, of course, that “repeal and replacing” is easier said than done, and indeed the President-elect has already begun to fudge. But moving forward on his broad replacement themes—expanding health savings accounts (HSAs) and state flexibility—could lead to some surprising and intriguing reforms.

Building Blocks for Addressing Social Determinants of Health

Seemingly modest reforms could profoundly alter the health care system, warns Stuart Butler.

Why Replacing the ACA Has Republicans in a Tizzy

professor of nursing at West Virginia University in Morgantown. In reality, though, loneliness is a psychological construct linked to depression and anxiety, said Theeke, who has developed an intervention called LISTEN, which stands for “Loneliness Intervention using Story Theory to Enhance Nursing-sensitive outcomes.” Theeke and her collaborators recently published the results of a pilot study of LISTEN and are now seeking funding to conduct a larger study. The pilot included 27 cognitively normal adults (only 3 were men) who, to avoid confounding because of the grief reaction, had not lost a spouse in the previous 2 years. They were randomized to the LISTEN intervention or to a control group and met in groups of 3 to 5 with a facilitator for 5 weekly 2-hour sessions. Those in the control group received educational information about aging, while LISTEN participants talked about patterns of thought and behavior that were contributing to their perception of loneliness. “There is a stigma associated with loneliness, and it’s the stigma of social undesirability,” she said. But LISTEN participants learn that “it’s okay to have loneliness and to say it. They like hearing that they’re not the only person who feels this way.” They talked about times in their life when they weren’t lonely, shared ways that they met the challenge of living with loneliness, and identified potential new solutions to their loneliness. To put it simply, Theeke said, “LISTEN is like teaching a person how to fish.” Twelve weeks after the last session, LISTEN participants reported reduced loneliness, enhanced social support, and decreased systolic blood pressure compared with baseline. On the other hand, the control group reported decreased functional ability and reduced quality of life. Several people who completed the LISTEN study made major life changes afterward, Theeke said. For example, an 89-year-old woman realized that the times in her life that she was least lonely were when she lived with or near her daughter. After completing the study, the woman decided to move to her daughter’s town several states away. Although the pilot study was geared toward older adults, Theeke thinks LISTEN would also work with younger people. “We designed LISTEN to help people reconnect with their own individualized need to belong. I think that’s why it works,” said Theeke, adding that she hopes eventually to offer LISTEN online as well as face-to-face.

Strengthening the Affordable Care Act: The Need for Strategic Building Blocks

Recently, President Trump correctly described health care policy making as “unbelievably complex”— although his comment that “nobody knew that” must have been a surprise to the many analysts and lawmakers who for decades have worked on health care reform. Health care policy making is technically complex, of course. But it is also complex in that the president and Republicans seeking to replace the Affordable Care Act (ACA) face very difficult political and philosophical choices. It was evident from the internal backlash to the recent Republican House committee bills that there is a deep divide among Republicans on these choices. Consider 3 such tough issues: deciding what coverage means, making hard choices about subsidies, and determining how to cover people with chronic illnesses.

Economics of health care reform

The Affordable Care Act (ACA) is best seen as transitional legislation on the road to long-term structural reform of the US health care system. This is not so much because the ACA is politically controversial and there is bound to be pressure for changes, despite the US Supreme Court’s King v Burwell decision,1 but rather it is because the ACA’s design still lacks the consistent, strategic building blocks needed for a stable, long-term system redesign. Congress could make amendments to the ACA that would largely complete the necessary strategic building blocks. Moreover, even though not everyone would agree, 4 key changes could command broad support.

Don’t Let Budget Cuts Wreck Medicare Reform

Several economic points require consideration when assessing the current cost of health care in the United States and the potential savings from proposed reforms. Most savings projections are based on assumptions and estimates that cannot be accurate under the best of circumstances, and the error in the final results is greatly compounded by even small errors in the initial estimates. Experience with health care programs worldwide, including our own Medicare program, has shown that final costs are usually much larger--often several times larger--than initial estimates. It is even more difficult to predict the behavior of the population under a system that does not yet exist, and it is not clear whether a system such as the Jackson Hole Plan will actually produce savings. The effect of our political system will have on any health system enacted through legislation must also be considered. The political process itself frequently results in more benefits rather than fewer, more regulation rather than less, and the shifting of costs to other sectors of the economy to minimize costs in the health sector. When presented with projections and predictions in health care planning, we must critically examine the initial assumptions, knowing that errors in these assumptions will magnify errors in the final results.