remaking the affordable care act (aca); the future
DESCRIPTION
Remaking the Affordable Care Act (ACA); The Future. Pauline Vaillancourt Rosenau Management , Policy, and Community Health School of Public Health University of Texas Health Science Center Houston, Texas, USA September 21, 2011 www.prosenau.com Email: [email protected]. - PowerPoint PPT PresentationTRANSCRIPT
REMAKING THE AFFORDABLE REMAKING THE AFFORDABLE CARE ACT (ACA); THE CARE ACT (ACA); THE
FUTUREFUTURE
Pauline Vaillancourt RosenauManagement , Policy, and Community Health
School of Public HealthUniversity of Texas Health Science Center
Houston, Texas, USA
September 21, 2011
www.prosenau.comEmail: [email protected]
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Pauline Rosenau; US Health System Reform 2011
OVERVIEW & DISCLAIMER
The ACA is a product of leaders, not the public
Repeal unlikely Predicting the future; surprising
evidence and policy assessments Employment Compensation
Supreme Court decisions predicted Future of Congressional action – less
predictable 2
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ACA IS A PRODUCT OF ACA IS A PRODUCT OF LEADERS, NOT THE PUBLICLEADERS, NOT THE PUBLIC
Public support low all along!Knowledge of the bill has declinedBroad public misinformation, February 2011
20% think the ACA already repealed 26% think if might have been, not sure 52% think it is still the law: February 2011 http://www.kff.org/kaiserpolls/upload/8156-F.pdf
47% say the bill “won’t make much difference” August 2011
Those to benefit most, either don’t know that or say 2014 is “too far away” 3
Pauline Rosenau; US Health System Reform 2011
LIVING WITH THE ACA Wall Street expects agree: “repeal highly
unlikely” Implementation stretches from 2010 to
2020 States to do the heavy lifting – variation
Exchanges Rate increases, etc.
Default 4
Pauline Rosenau; US Health System Reform 2011
FEW FEW STAKEHOLDERS STAKEHOLDERS WANT REPEAL!WANT REPEAL!
Few would benefit: Hospital groups Doctor groups Pharmaceutical manufacturers Employers Health insurers
Prefer to stay with it and make changes rather than repeal and/or start over
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Pauline Rosenau; US Health System Reform 2011
WHY?WHY?The ACA is the “Law of the
Land” New business model required Costly investment up-front “Not to have it in your
strategic plan would be foolish”
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Pauline Rosenau; US Health System Reform 2011
Pauline Rosenau; US Health System Reform 2011
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STATES AS STATES AS “STAKEHOLDERS”“STAKEHOLDERS”
Not like the others Less effective at lobbying
Late “to the table” Politically divided
Court challenges BUT will take the money ….. Governors get lots of flexibility
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Pauline Rosenau; US Health System Reform 2011
HOW DID THE MD HOW DID THE MD COMMUNITY LINE UPCOMMUNITY LINE UP
Support: AAMC (Association of American Medical
Colleges) AMA – ACOG “qualified support” – “lots to like”
http://www.ama-assn.org/ama/pub/health-system-reform/hsr-impacts-practice.shtml
Did not supportTexas Medical Association – Austin
American- Statesman 22-23 March 2010
Physicians for a National Health Program http://www.pnhp.org/
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Pauline Rosenau; US Health System Reform 2011
CAN HOSPITALS MAKE MONEY CAN HOSPITALS MAKE MONEY UNDER THE ACA?UNDER THE ACA?
Some say yes (Mahar 2010; Hackbarth 2009):
Efficiency and quality outcomes improve – payment increases
Coverage increases - reduce uncompensated care
Others say “no way” (Savings and Goodman 2010)
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Pauline Rosenau; US Health System Reform 2011
EVIDENCE FROM MASSACHUSETTS; THE MECHANICS OF IMPLEMENTATION OF A
VERY SIMILAR HEALTH SYSTEM
Uninsured rates plummet Demand up Costs not controlled Newly insured stay with safety-net
providers and community clinics How to compete for “newly insured” (Arch.
Intern. Med .Aug 8/22 2011)
“Perceived quality and convenience”
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Pauline Rosenau; US Health System Reform 2011
SURPRISE EMPLOYMENT SURPRISE EMPLOYMENT EFFECTS IN MASS.EFFECTS IN MASS.
Healthcare becoming the dominant employment sector: Staiger NEJM 9/2011
Administrative burden higher; increased demand for managers, administrators, and support personnel Staiger , NEJM Sept. 2011
Little increased demand for physicians and nurses Staiger , NEJM Sept.
2011
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Pauline Rosenau; US Health System Reform 2011
PAYMENT SYSTEMS: MORE PAYMENT SYSTEMS: MORE “INNOVATIVE”, COMPLEX, AND “INNOVATIVE”, COMPLEX, AND
VARIED VARIED
More MDs on salary- at FQHCFewer fee-for-service systemsMore capitation paymentsBetter incentivized P4PSome ACOs for Medicare
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Pauline Rosenau; US Health System Reform 2011
COMPENSATION COMPENSATION CONSIDERATIONS…CONSIDERATIONS…CONTINUEDCONTINUED
2013-2014: better payment for MedicaidOver time: Medicare payments unlikely
to remain as high as they are now If doctors refuse Medicare/Medicaid
patients, where will they go? Answer: stay with safety-net providers or
move to Federally Qualified Health Centers
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Pauline Rosenau; US Health System Reform 2011
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WHATWHAT WILL THE WILL THE SUPREME COURT DO?SUPREME COURT DO?
Court will hold the Mandate Unconstitutional by Dec. 2012: Intrade predicts the likelihood as 22.5% http://www.intrade.com/v4/markets/?eventId=89280#
Court will hold the Mandate Unconstitutional by Dec. 2013: Intrade predicts the likelihood as 50% http://www.intrade.com/v4/markets/?eventId=89280#
ACA is Constitutional All of the ACA is unconstitutional - unlikely
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Pauline Rosenau; US Health System Reform 2011
WHENWHEN WILL THE WILL THE SUPREME COURT DO IT?SUPREME COURT DO IT?
Can take the case anytime: October through December 2011 - likely
Could rule before the 2012 election?
Could take the case in 2012 and then rule after the 2012 election?
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Pauline Rosenau; US Health System Reform 2011
THE MANDATE MAY BE THE MANDATE MAY BE UNCONSTITUTIONALUNCONSTITUTIONAL
Pressure from insurers is on! Congress could fix it….
Buy now or pay more later ; late enrollment penalties, no uncompensated care reimbursed
Open enrollment expanded to two years or longer (Uccello)
Opt out without a penalty, for 5 years but results in big limits on individual (Starr)
Status quo – not required to purchase but 2 year preexisting conditions in effect
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Pauline Rosenau; US Health System Reform 2011
2013 CONGRESS WILL DECIDE THE FUTURE OF MEDICINE
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WHAT WILL CONGRESS WHAT WILL CONGRESS DO AFTER THE 2012 DO AFTER THE 2012
ELECTION?ELECTION?
Who will be president?Which party will win the
House?Which party will win the
Senate?20
Pauline Rosenau; US Health System Reform 2011
CONGRESS CAN WITHHOLD FUNDING FOR IMPLEMENTATION?
It already has for some elements
Pilot programs have gone unfunded
Not all new elements require funding
Absence of funding results in delay or “repeal” without the hassle
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CONGRESS CAN CHANGE THE ACA
Reduce subsidies to help low income people buy insurance Who’s against? Who’s for?
Reduce funds to the States Payments for Medicaid Exchanges
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