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Remaking the Affordable Care Act (ACA); The Future

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: pauline.rosenau@uth.tmc.edu.

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Remaking the Affordable Care Act (ACA); The Future

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  1. 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: pauline.rosenau@uth.tmc.edu Pauline Rosenau; US Health System Reform 2011

  2. 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 Pauline Rosenau; US Health System Reform 2011

  3. ACA Is A Product of Leaders, Not the Public • Public support low all along! • Knowledge of the bill has declined • Broad public misinformation, February 2011 • 20% think the ACA already repealed • 26% think if might have been, not sure • 52% think it is still the law: February 2011 http://www.kff.org/kaiserpolls/upload/8156-F.pdf • 47% say the bill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” Pauline Rosenau; US Health System Reform 2011

  4. 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 Pauline Rosenau; US Health System Reform 2011

  5. Few Stakeholders 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 Pauline Rosenau; US Health System Reform 2011

  6. 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” Pauline Rosenau; US Health System Reform 2011

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  8. States as “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 Pauline Rosenau; US Health System Reform 2011

  9. How Did the MD Community 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 notsupport • Texas Medical Association – Austin American- Statesman 22-23 March 2010 • Physicians for a National Health Program http://www.pnhp.org/ Pauline Rosenau; US Health System Reform 2011

  10. Can Hospitals Make Money 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) Pauline Rosenau; US Health System Reform 2011

  11. 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” Pauline Rosenau; US Health System Reform 2011

  12. Surprise Employment 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 Pauline Rosenau; US Health System Reform 2011

  13. Payment systems: more “innovative”, complex, and varied • More MDs on salary- at FQHC • Fewer fee-for-service systems • More capitation payments • Better incentivized P4P • Some ACOs for Medicare Pauline Rosenau; US Health System Reform 2011

  14. Compensation Considerations…Continued • 2013-2014: better payment for Medicaid • Over 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 Pauline Rosenau; US Health System Reform 2011

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  16. What will the 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 Pauline Rosenau; US Health System Reform 2011

  17. When will the 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? Pauline Rosenau; US Health System Reform 2011

  18. The Mandate May Be Unconstitutional • 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 Pauline Rosenau; US Health System Reform 2011

  19. 2013 Congress Will Decide the future of Medicine Pauline Rosenau; US Health System Reform 2011

  20. What Will Congress Do after the 2012 Election? • Who will be president? • Which party will win the House? • Which party will win the Senate? Pauline Rosenau; US Health System Reform 2011

  21. 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 Pauline Rosenau; US Health System Reform 2011

  22. 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 Pauline Rosenau; US Health System Reform 2011

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