I wrote this column for Commonwealth Magazine on the 5th anniversary of the ACA’s signing on March 23. In case you did not see it, there are messages in here helpful to Americans in understanding this massive policy change. Let me know what you think. One correction: the decline in some hospital acquired conditions referenced near the end of the column can be traced to the early 2000s and has accelerated significantly in the past five years.
On the fifth anniversary of the signing of the Affordable Care Act, I ponder how non-Americans view our momentous and controversial health reform law. Like many US health policy analysts, I get requests from groups outside the US to explain the ACA, or “Obamacare.” I have traveled to Brazil, Australia, and South Africa, and also addressed foreign audiences here in the US, to explain what they should they know about the law and why they might care. I offer them two conclusions, and believe Americans might benefit by knowing them. They are: we remain laggards in providing access to health care coverage, and we are now real leaders in global efforts to improve health care’s quality, efficiency, and effectiveness.
First, when it comes to providing universal coverage and financial protection from the costs of illness and injury, non-Americans have almost nothing of value to learn from us. Even after the ACA’s health insurance expansions are fully implemented by 2016-2017, the US will still have the most inefficient, expensive, wasteful, and unfair coverage system of any advanced nation on the planet.
Long before President Obama signed the ACA in 2010, every other developed nation had established a system to provide universal coverage for all their citizens. Each found its own idiosyncratic path, using differing measures of market and government intervention to align with their distinct economic and political cultures. They all did it better than the ACA ever will.
Make no mistake, for Americans the ACA represents a quantum leap forward in providing more secure and comprehensive coverage and financial protection. It does so by eliminating coverage denials because of pre-existing conditions, lifetime and annual coverage limits, and much more. Since the major insurance expansions took effect on January 1, 2014, 16.4 million formerly uninsured Americans now have coverage. In years ahead, I hope Americans will press for and win improvements to make the ACA fairer and better.
Yet, even after full implementation, 25-30 million Americans will still be uninsured, especially in states refusing to expand their Medicaid programs. Too many Americans will have insurance with high deductibles and limits on physician and hospital choice. Further, for most non-elderly Americans, the quality of access to medically necessary care is still determined by place of employment, leaving gaping disparities in benefits, premiums, cost-sharing, and provider access.
Today, universal health insurance is a global movement, as developing nations recognize that coverage is crucial to economic growth and societal development. My advice to everyone outside the US: Enjoy watching the spectacle of Americans beating ourselves senseless in the Obamacare political furor – think of it as World Cup health politics. Just look elsewhere for sound policy guidance.
Yet, when it comes to improving the quality, efficiency, effectiveness and cost of medical care, nations have lots to learn from each other and the ACA is a globally important milestone. Though the ACA does not provide the answer to these challenges facing nearly every nation, it is one of the most aggressive and impressive set of initiatives and experiments ever developed to improve medical care delivery. These initiatives include accountable care organizations, patient-centered medical homes, value based insurance design, physician and hospital quality reporting, hospital penalties for readmissions and hospital acquired conditions, and much more.
Nearly every nation on earth confronts a similar dilemma, demands for medical services and resources far outstripping normal economic growth, forcing unending reductions for other valued public goods such as education, environmental protection, and economic development. Many nations, including the US, are struggling to move their health systems away from fee-for-service financing that rewards volume over quality and efficiency and toward accountable care and paying for value and outcomes. Because of the ACA, the US is now in the vanguard of this global movement.
In the past several years, for the first time, we’ve seen real reductions in readmissions of Medicare patients to hospitals as well as reductions in hospital acquired infections, falls, and medication errors. According to the US Agency for Healthcare Research and Quality, 35,000 fewer American died in hospitals between 2011 and 2013 because of these improvements. For the first time since the 1990s when the US awakened to the astonishing levels of poor quality and medical errors in our system, the needle is moving in the right direction.
While some ACA innovations will fail or disappoint, more will point the way toward even more meaningful improvements. Systemic improvement is a process, not a destination and the ACA’s innovations are a start, not the finish. When Congress tires of the endless conflict over providing affordable health insurance to needy Americans, we can hope they finally will turn their attention to continuous policy improvement of the ACA’s globally important system innovations.