By Jonathan Gruber and Benjamin D. Sommers
National Bureau of Economic Research, June 2019
As we approach the tenth anniversary of the passage of the Affordable Care Act, it is important to reflect on what has been learned about the impacts of this major reform. In this paper we review the literature on the impacts of the ACA on patients, providers and the economy. We find strong evidence that the ACA’s provisions have increased insurance coverage. There is also a clearly positive effect on access to and consumption of health care, with suggestive but more limited evidence on improved health outcomes. There is no evidence of significant reductions in provider access, changes in labor supply, or increased budgetary pressures on state governments, and the law’s total federal cost through 2018 has been less than predicted. We conclude by describing key policy implications and future areas for research.
From the Conclusion
Disentangling which aspects of the ACA have the largest impacts will be critical as policymakers consider both selective restrictions and expansions of the law’s provisions. The effect of the individual mandate repeal and potential barriers to coverage such as Medicaid work requirements have been the focus of recent political discussions, while early forays into health policy among Democratic presidential contenders often focus on making exchange plans more affordable. Understanding the effects not just of having any health insurance but the particular type of coverage also has important implications for health care quality, costs, and patient outcomes. A better understanding of coverage heterogeneity is particularly critical as state and federal policymakers propose a wide range of solutions, such as a public option on the insurance marketplace, moving more Medicaid beneficiaries to private coverage, and – most dramatically – “Medicare-for-All” in various configurations. Ongoing studies of these issues are warranted to continue to inform changes to the ACA and the U.S.’s health insurance system more broadly in the coming years.
By Don McCanne, M.D.
Jonathan Gruber and Benjamin Sommers are certainly highly qualified to describe what a decade of the Affordable Care Act has done for health care in the United States. The most important change has been to increase the numbers of Americans who are insured, predominantly through the Medicaid program, along with an improvement in health care access that being insured provides. The remaining improvements are fairly negligible when compared to the need that existed ten years ago and the need that still exists.
The authors tell us that we need ongoing studies of potential solutions such as “a public option on the insurance marketplace, moving more Medicaid beneficiaries to private coverage, and – most dramatically – ‘Medicare-for-All’ in various configurations.” So just what studies do we need?
- Presumably we want everyone to be included. Current studies have shown that, in spite of the increase, we have fallen far short of universality. So when we set up a system that automatically includes everyone, what study do you need to find out if everyone ends up being included? Well, the health policy academics don’t have to do a study of that one since anyone who is discovered to not be enrolled is automatically enrolled on the spot.
- The financial burden of underinsurance has grown worse since deductibles are increasing. So what study do you need to find out how much of a financial burden the patients would face when out-of-pocket health care spending is eliminated (as with HR 1384, Jayapal)? Well, that lets the policy academics off the hook again since there is no underinsurance if there are no medical bills for cost-sharing that has already been eliminated.
- Insurance premiums are a burden for working families who do not qualify for government subsidies. Single payer Medicare for All legislation would eliminate regressive insurance premiums and replace them with progressive taxes that would make health care affordable for everyone. What study do you need to show paying less in taxes would cost the family less than paying more in insurance premiums and other out-of-pocket costs? Do we really even need to ask that question?
- Provider networks, which are a tool to benefit the private insurers, take away from patients choices in their health care while potentially exposing them to higher costs because of surprise bills and out-of-network care. What study do we need of out-of-network care when there is only one universal network for the entire nation, and everyone is automatically included in the network?
- Our unique American health care financing system has already been demonstrated to waste a tremendous amount of funds on administrative excesses, and the Affordable Care Act added even more administrative requirements. It has been shown in other nations that these administrative excesses are not necessary, and, by design, would be dramatically reduced by enacting and implementing single payer Medicare for All. We wouldn’t need the academic policy community to tell us that waste would be drastically reduced, but it might be informative for them to do another study showing us how many hundreds of billions of dollars we would be saving by recovering that waste – savings that could be spent on health care instead.
- With regional planning and separate capital budgets we could improve capacity in regions of need thereby improving access to care in areas that are currently underserved, while avoiding excess capacity that can result in overutilization. Do we really need a study to show us that spending money where it is needed better meets the need?
“Ongoing studies of these issues are warranted to continue to inform changes to the ACA…” Really? The overwhelming evidence is that this decade with the Affordable Care Act has demonstrated that it has largely been a failure in achieving universality, elimination of financial hardship from medical bills, affordability for individuals and society, equity, portability, accessibility, administrative efficiency, and a failure of our health policy community to advance reform that would clearly benefit all of America.
That doesn’t mean that Gruber, Sommers and their colleagues in health policy should be out of a job. Look at price and volume in health care – the two mathematical determinants of spending. For instance, when a new drug comes on the market with a $2 million price tag for a single dose, wouldn’t it be helpful to know if it is priced properly? When a preventive measure is being used by millions of individuals, wouldn’t it be helpful to know if it is really effective in preventing what it is alleged to prevent? Surely they can devise a multitude of studies that are designed to help… guess what… the patient!
We’ve had enough studies that are designed to help insurers and passive investors in the medical-industrial complex when they shouldn’t even be in the picture anymore. Kenneth Arrow, who showed that health care markets do not work for patients, was awarded the Nobel Prize. Maybe there are more Nobels for the health policy community if they will only apply their science to the betterment of health for all of us.
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