Category Archives: Deferred Healthcare

In ‘American Hospitals’ Pride Comes Before the Fall

Posted on by • Posted in Administrative Burden, Cost Management, Cost Reduction, Cost Structure, Customer Service, Deferred Healthcare, Health Insurance Coverage Adequacy, Health Policy, Health System, Healthcare Reform, High Prices, Hospital, Hospital Industry, Innovation, Medical Debt, Medical Ethics, Outcomes, Quality of Care, Right Size, Underinsured, Uninsured, Unnecessary Care • Leave a comment
In ‘American Hospitals’ Pride Comes Before the Fall

The film “American Hospitals: Healing a Broken System” premiered in Washington, D.C., on March 29. This documentary exposes the inconvenient truths embedded within the U.S. healthcare system. Here is a dirty dozen of them:

  1. Over half of hospital care is unnecessary, either wasteful or for preventable acute conditions.
  2. Administrative costs account for 15-25% of total healthcare expenditures.
  3. U.S. per-capita healthcare spending is more than twice the average cost of the world’s 12 wealthiest countries.
  4. Medical debt is a causal factor in two-thirds of all personal bankruptcies.
  5. American adults fear medical bills more than contracting a serious disease. Nearly 40% of Americans — a record — delayed necessary medical care because of cost in 2022.
  6. Low-income urban and rural communities lack access to basic healthcare services.
  7. The financial benefits of tax exemption for hospitals are far greater than the cost of the charitable care they provide.
  8. Medical error is unacceptably high.
  9. Hospitals are largely unaccountable for poor clinical outcomes.
  10. The cost of commercially insured care is multiples higher than the cost of government-insured care for identical procedures.
  11. Customer service at hospitals is dreadful.
  12. Frontline clinicians are overburdened and leaving the profession in droves.

Healthcare still operates the same way it has for the last one hundred years — delivering hierarchical, fragmented, hospital-centric, disease-centric, physician-centric “sick” care. Accordingly, healthcare business models optimize revenue generation and profitability rather than health outcomes. These factors explain, in part, why U.S. life expectancy has declined four of the five years and maternal deaths are higher today than a generation ago.

It’s hard to imagine that the devil itself could create a more inhumane, ineffective, costly and change-resistant system. Hospitals consume more and more societal resources to maintain an inadequate status quo. They’re a major part of America’s healthcare problem, certainly not its solution. Even so, hospitals have largely avoided scrutiny and the public’s wrath. Until now.

“American Hospitals” is now playing in theaters throughout the nation. It chronicles the pervasive and chronic dysfunction plaguing America’s hospitals. It portrays the devastating emotional, financial and physical toll that hospitals impose on both consumers and caregivers.

Despite its critical lens, “American Hospitals” is not a diatribe against hospitals. Its contributors include some of healthcare’s most prominent and respected industry leaders, including Donald Berwick, Elizabeth Rosenthal, Shannon Brownlee and Stephen Klasko. The film explores payment and regulatory reforms that would deliver higher-value care. It profiles Maryland’s all-payer system as an example of how constructive reforms can constrain healthcare spending and direct resources into more effective, community-based care.

The United States already spends more than enough on healthcare. It doesn’t need to spend more. It needs to spend more wisely. The system must downsize its acute and specialty care footprint and invest more in primary care, behavioral health, chronic disease management and health promotion. It’s really that simple.

My only critique of “American Hospitals” is many of its contributors expect too much from hospitals. They want them to simultaneously improve their care delivery and advance the health of their communities. This is wishful thinking. Health and healthcare are fundamentally different businesses. Rather than pivoting to population health, hospitals must focus all their efforts on delivering the right care at the right time, place and price.

If hospitals can deliver appropriate care more affordably, this will free up enormous resources for society to invest in health promotion and aligned social-care services. In this brave new world, right-sized hospitals deliver only necessary care within healthier, happier and more productive communities.

All Americans deserve access to affordable health insurance that covers necessary healthcare services without bankrupting them and/or the country. Let me restate the obvious. This requires less healthcare spending and more investments in health-creating activities. Less healthcare and more health is the type of transformative reform that the country could rally behind.

At issue is whether America’s hospitals will constructively participate in downsizing and reconfiguring the nation’s healthcare system. If they do so, they can reinvent themselves from the inside out and control their destinies.

Historically, hospitals have preferred to use their political and financial leverage to protect their privileged position rather than advance the nation’s well-being. Like Satan in Milton’s “Paradise Lost,” they have preferred to reign in hell rather than serve in heaven.

Pride comes before the fall. Woe to those hospitals that fight the nation’s natural evolution toward value-based care and healthier communities. They will experience a customer-led revolution from outside in and lose market relevance. Only by admitting and addressing their structural flaws can hospitals truly serve the American people.

Inflation supercharging cost-sharing challenges in healthcare

Posted on by • Posted in Affordability, Deferred Healthcare, Health Insurance Coverage Adequacy, Health System, High Deductible Health Plans, High Prices, Hospital, Hospital Industry, Inflation, Primary Care, Underinsured, Uninsured • Leave a comment

https://mailchi.mp/59374d8d7306/the-weekly-gist-january-13-2023?e=d1e747d2d8

After COVID fears and shutdowns led consumers to delay care early in the pandemic, persistently high inflation over the past year has further suppressed volumes.

As the graphic above illustrates, the average deductible for individual coverage has grown by over 140 percent since 2010, exposing consumers to an increasing portion of healthcare costs, and prompting economists to reevaluate the adage that healthcare is “recession-proof”. 

This year, that trend collided with an inflation spike that outpaced wage gains by two percent. Faced with diminished purchasing power, households are making budget tradeoffs which explicitly pit healthcare against other essential household needs. 

For some, this cost-cutting impulse even extends to preventative screenings—required to be covered without cost-sharing—when consumers’ financial concerns drive them to avoid healthcare altogether. 

While the latest inflation report suggests price increases are moderating, fears of a broader recession persist, making it critical for health systems and physicians to communicate with patients, encouraging them to continue to access preventive care, educating them about lower cost care options, and helping them prioritize treatment that should not be put off. 

The dire state of hospital finances (Part 1: Hospital of the Future series)

Posted on by • Posted in Administrative Footprint, Average Length of Stay (ALOS), Business Model, Business Transformations, Clinical Management of Complex Patients, Cohesive Care Teams, Competition, Cost Management, Cost Reduction, Deferred Healthcare, Disruption, Elective Procedures, Elective Surgery, Employee Layoffs, Employee Loyalty, Employee Staffing, Employee Staffing Shortage, Experience Complexity Gap, External Market Forces, Financial Instability, Financial Pressure, Financial Stewardship, Financial Strength, Financial Viability, Financially Distressed, Health System, High Deductible Health Plans, Home-Based Care, Hospital, Hospital Industry, Inflation, Innovation, Labor Cost Structure, Labor Market, Labor Shortages, Labor Spend Management, Leadership, Mission, Nonoperating Income, Nonoperating Income Dependency, Nurse Agency Staffing, Nurse Retention, Nurse Staffing, Operating Expense Reduction, Operating Expenses, Operating Income, Operating Margin, Operating Metrics, Operating Performance, Operating Revenue, Outpatient Care, Outpatient Surgery, Patient Demand, Patient Safety, Payor Contracting, Payor Mix, Post Acute Care, Quality of Care, Rationalization, Recession, Reorganization, Retention, State of the Union, Strategy, Strategy Sustainable Long Term, Streamlining Operations, Supply Chain, Talent Acquisition Strategy, Talent Competition, Talent Management, Turnover, Turnover Rates, Work Life Balance, Work-Life Balance, Workforce Challenges, Workforce Strategy • Leave a comment
https://radioadvisory.advisory.com/142?utm_source=member_db&utm_medium=email&utm_campaign=2022Dec22&utm_content=member_trendingnow_final_x_x_x_x&elq_cid=4838956&x_id=0033b00002owB9sAAE

About this Episode

The majority of hospitals are predicted to have negative margins in 2022, marking the worst year financially for hospitals since the beginning of the Covid-19 pandemic.

In Part 1 of Radio Advisory’s Hospital of the Future series, host Rachel (Rae) Woods invites Advisory Board experts Monica Westhead, Colin Gelbaugh, and Aaron Mauck to discuss why factors like workforce shortages, post-acute financial instability, and growing competition are contributing to this troubling financial landscape and how hospitals are tackling these problems.

Links:

As we emerge from the global pandemic, health care is restructuring. What decisions should you be making, and what do you need to know to make them? Explore the state of the health care industry and its outlook for next year by visiting advisory.com/HealthCare2023.

Patients Are Delaying Healthcare – Findings From 2022 BDO Patient Experience Survey

Posted on by • Posted in Consumer Engagement, Consumer Experience, Consumer Preferences, Consumer-Centric, Consumerism, Cost Transparency, Deferred Healthcare, Health System, Hospital, Hospital Industry, Patient Conveniance, Patient Experience, Patient Satisfaction • Leave a comment

https://www.linkedin.com/pulse/patients-delaying-healthcare-findings-from-our-new-survey-shill/

Since the early days of the pandemic, the healthcare industry has faced seemingly insurmountable challenges to ensure access to high-quality care. While healthcare providers have performed admirably in the face of these challenges, patients are still seeing access challenges that are impacting their behaviors — which can lead to challenges in the long run.

In the 2022 BDO Patient Experience Survey, they sought to learn how patients feel about their providers and healthcare experience — from making appointments and interacting with care providers, to how patients access health insurance and who patients turn to for routine care.

From the survey of over 3,000 U.S. adults, they came across a few key takeaways:

 1. Delaying routine care is the new norm

Americans face a troubling dilemma: While 92% have health insurance and 91% have a regular care provider, 58% admit to delaying routine medical care in the past 12 months.

For routine (non-emergency) care, 69% of respondents report seeing a primary care physician and 12% routinely visit primary care nurse/nurse practitioner or physician assistant. Just 9% do not have a provider for routine medical care. Our survey found that Americans use a wide variety of health insurance options with employer-sponsored insurance (32%) being the most popular, followed by Medicare (28%), Medicaid (14%) and individual private insurance (7%). While 8% report having no health insurance, even those with insurance faced significant barriers to care.

Of those who delayed seeking medical care in the past 12 months, 30% cite unaffordability due to high out-of-pocket costs and 19% say they could not afford to seek care due to a lack of insurance. In addition to the high costs of medical care, many Americans struggle with a lack of cost transparency.

 2. Cost transparency is a continuing problem

Nearly a third of Americans (31%) have never tried to obtain cost estimates for medical care. When patients do not know what healthcare will cost, many avoid seeking necessary care. A critical way we can improve patient access to healthcare is to understand how patients like to obtain cost estimates.

Of patients surveyed who have sought cost estimates, most prefer to reach out to a person, with 38% preferring to contact their insurance provider and 37% opting to ask the healthcare provider’s administrative staff. On the digital side, 31% say they obtained cost estimates by looking at online patient portals and 27% look to health provider or medical facility websites.

3. Most patients experience frustration when seeking and receiving care

We know that long appointments lead times and high costs cause patients to put off care — but how do patients feel about the actual care they receive? 69% of Americans experience frustration during routine medical appointments, with having to wait for a late provider (29%), not getting enough time with the provider (22%) and having too much paperwork to fill out (21%) being the most common frustrations.

 When providers make it easier for patients to receive care, their efforts are noticed. Patients say providers make care more accessible by offering telehealth appointments (32%), reaching out to proactively schedule appointments (29%), offering walk-in appointments (27%) and implementing online/self-service scheduling (23%).

Patients are facing a challenging care environment — and so are providers. Fortunately, there are ways that providers can improve access and the care experience for their patients without breaking their budgets.

Massachusetts’ 19K vacant hospital jobs: ‘Our healthcare system has never been more fragile’

Posted on by • Posted in Deferred Healthcare, Demand, Employee Staffing Shortage, Health System, Hospital, Hospital Industry, Inflation, Labor Shortages, Labor Spend Management, Market Outlook, Market Trends, Market Uncertainty, Nurse Agency Staffing, Nurse Staffing, Nurses Shortage, Operating Expense Reduction, Operating Expenses, Operating Income, Operating Margin, Operating Metrics, Operating Performance, Vacancy Rate • Leave a comment
https://www.beckershospitalreview.com/finance/massachusetts-19k-vacant-hospital-jobs-our-healthcare-system-has-never-been-more-fragile.html?utm_medium=email&utm_content=newsletter

There are an estimated 19,000 full-time job vacancies across Massachusetts acute care hospitals, according to a survey published Oct. 31 by the Massachusetts Health & Hospital Association.

Hospitals are working to address backlogs and transfer patients to post-acute care settings while skyrocketing labor costs — including a projected $1 billion in travel labor costs this year — are compounding healthcare facilities’ financial woes, according to the report. These challenges are hampering hospital operations as well as leading to care delays and reduced access to care.

Fewer workers mean that fewer beds are available for patients, while the demand for care increases due to deferred care throughout the COVID-19 pandemic, the behavioral health crisis and reduced access to community-based services continue to challenge hospitals throughout the state. At any given time, more than 1,500 patients are in acute hospital beds awaiting placement to a specialized behavioral health bed or post-acute care, according to the MHA.

“Our healthcare system has never been more fragile, and its leaders have never been more concerned about what’s to come in months ahead,” Steve Walsh, president and CEO of the MHA, said in an Oct. 31 news release shared with Becker’s Hospital Review. “They are exhausting every option within their control to confront these challenges, but this is an unsustainable reality and providers are in dire need of support.”

In response to the survey, 37 hospitals — representing 70 percent of the state’s total hospital employment — reported 6,650 vacancies among 47 positions critical to hospital operations and clinical care. The positions range from direct care nurses to lab personnel and clinical support staff. Eighteen of the 47 positions have a vacancy rate greater than 20 percent. 

At a 56 percent vacancy rate, licensed practical nurses is the most in-demand position, while home health aides (34 percent), mental health workers (32 percent), infection control nurses (26 percent) and CRNAs (24 percent) are also highly sought after.

Survey respondents identified 6,650 vacancies. The 47 positions included in the survey, which was conducted this summer, account for less than half of all hospital roles. The MHA said it extrapolated that across all positions and hospitals to arrive at an estimated 19,000 vacancies across the state.

Staffing shortages are driving labor costs to an unsustainable level for many hospitals already grappling with margins close to zero or in the red. Hospitals have relied on high-cost temporary staffing to fill critical positions during the pandemic, resulting in average hourly wage rates for travel nurses increasing 90 percent since 2019, according to the report. Massachusetts hospitals reported spending $445 million on temporary registered nurse staffing halfway through the fiscal year, with temporary RN staffing costs increasing 234 percent from fiscal year 2019 to March 2022.

If urgent steps are not taken to address healthcare’s staffing shortage, hospitals will continue to face capacity challenges and overpay for labor, which will lead to fiscal instability, according to Mr. Walsh. 

The MHA urged providers, payers, public officials and government agencies to address the workforce crisis by investing in training and education, expanding the workforce pipeline, providing financial support to hospitals and advancing new models of care such as telehealth and at-home care. 

Critics say Mark Cuban’s pharmacy isn’t tackling the big issue: brand-name drugs

Posted on by • Posted in Deferred Healthcare, Health Policy, High Deductible Health Plans, High Drug Prices, Out of Pocket Expenses, Pharmaceutical Industry, Profit Margin, Profit Model, Profit Motive • Leave a comment
https://www.beckershospitalreview.com/pharmacy/critics-say-mark-cuban-s-pharmacy-isn-t-tackling-the-big-issue-brand-name-drugs.html?utm_medium=email&utm_content=newsletter

Mark Cuban’s pharmacy, Cost Plus Drug Co., has hundreds of drugs marked at discounted prices, but some pharmacy experts say there’s a larger problem that needs fixing, CNBC reported July 28. 

The online pharmacy launched in January with about 100 drugs, and by its one-year anniversary, plans to have more than 1,500 medications, according to the company’s website. The business model, which allocates for a $3 pharmacy dispensing fee, $5 shipping fee and a 15 percent profit margin with each order, aims to uproot the pharmaceutical industry, which has faced criticism for years about its opaque business practices. 

Gabriel Levitt, the president of PharmacyChecker, a company that monitors the cheapest drug prices, told CNBC there’s more to be done.

“As much as I support the venture, what they’re doing does not address the big elephant in the room,” Mr. Levitt said. “It’s really brand-name drugs that are increasing in price every year and forcing millions of Americans to cut back on medications or not take them at all.”

Brand-name drugs are 80 percent to 85 percent more expensive than generics since brand-name drugs have to repeat clinical tests to prove efficacy, according to the FDA. Cost Plus Drug Co. only offers generics. Mr. Cuban told CNBC he hopes to sell brand-name medications “within six months,” but added that it’s a tentative timeline.

Finances of older Americans being dinged by high health costs, survey finds

Posted on by • Posted in Deferred Healthcare, Health Insurance Coverage Adequacy, Health Policy, Hidden Fees, High Deductible Health Plans, High Drug Prices, High Premiums, High Prices, Out of Pocket Expenses • Leave a comment

https://www.healthcaredive.com/news/finances-older-americans-being-dinged-high-health-costs-survey-finds/625545/

Dive Brief:

  • Healthcare costs are becoming an increasing source of stress for older Americans, leading to some paring back on treatment, medicines or other spending on food and utilities — or skipping them altogether — to cover medical costs, according to new research conducted by Gallup in partnership with West Health.
  • The survey of U.S. adults released Wednesday found that almost half of adults aged 50 to 64 and more than a third of adults 65 and older are concerned they won’t be able to pay for needed healthcare services in the next year. That’s nearly 50 million older Americans.
  • About 80 million adults above age 50 see healthcare costs as a financial burden. Becoming eligible for Medicare seems to assuage those worries slightly, however: 24% of adults aged 50 to 64, who are not yet eligible for the federal health insurance, said health costs were a major burden. That percentage fell to 15% for those aged 65 and above.

Dive Insight:

The West Health-Gallup survey, conducted in September and October of 2021, is the latest vignette of how exorbitant healthcare costs in the U.S. are increasingly impacting the financial stability of Americans, especially those of retirement age who are more likely to have expensive medical needs.

Out-of-pocket healthcare expenses for adults aged 65 and older increased 41% from 2009 to 2019, according to HHS data. That population spends on average almost double their total expenditures on healthcare costs compared with the general population, despite Medicare coverage.

That cost problem is only likely to worsen amid surging inflation raising the cost of groceries, gas and other needed items. Additionally, U.S. demographics shifts are an added stressor. By 2030, the percentage of Americans 65 years and older will outweigh those under the age of 18, a first in the country’s history, according to Census Bureau projections.

The resulting stress on the Medicare program could impact benefits and cost for beneficiaries.

“As sizable numbers of Americans 65 and older face tangible tradeoffs to pay for healthcare, many more Americans in the next decade will incur health and financial consequences because of high costs,” researchers wrote in the report.

The West Health-Gallup poll found about one in four adults aged 65 and above cut back on food, utilities, clothing or medication to cover healthcare costs. That’s compared to three in 10 for adults aged 50 to 64.

Older women and Black adults were more likely to forgo basic necessities to pay for healthcare than other demographics.

More than 20 million Americans aged 50 years and above said there was a time within the last three months when they or a family member was sick, but didn’t seek treatment due to cost.

More than 15 million Americans said they or a family member skipped a pill or dose of prescribed medicine in order to save money.

Researchers urged policymakers to act to improve efficiency and reduce the costs of medical care and prescription drugs in the U.S. Congress has yet to take meaningful action to lower medical costs, despite rising support for government intervention and high-profile proposals from the Biden administration.

The domino effect of missed cancer screenings

Posted on by • Posted in Cancer, Cancer Screening, Cancer Testing, Cancer Treatment, Deferred Healthcare, Health System, Hospital, Hospital Industry, Oncology, Postponed Elective Procedures • Leave a comment

From delayed check-ups to postponed elective procedures, missed or deferred care during the pandemic will continue to strain the healthcare delivery system for the foreseeable future. The graphic above shows the impact on cancer care: both cancer screenings and new diagnoses are still down from pre-COVID levels.

Screenings for breast, colon, and cervical cancers were significantly lower in 2020, and patients missed about 10M total screenings in the pandemic’s first year alone. While cancer screenings rebounded somewhat in 2021, they were still below pre-pandemic levels. Unsurprisingly, the downstream impact has been a similar decline in new cancer diagnoses.

The negative effects of care delays have become increasingly obvious: there has been an increase in the number of patients presenting with later-stage cancers. There was a six percent increase in Stage 4 breast cancer diagnoses, and a 16 percent increase in Stage 2 and 3 cancer diagnoses in 2021, compared to 2019.

With no reason to believe that either cancer incidence or acuity has actually changed, oncology providers must increase their screening capacity and double down on reaching out to patients who are overdue for screenings. But as providers continue to work through the backlog of missed exams, they must prepare to treat more complex, higher-acuity cancer patients than ever before.

Health Agency Preparing for Lapse in Extra ACA Subsidies

Posted on by • Posted in ACA, Bad Debt Expense, Children's Health Insurance Coverage, Deferred Healthcare, Health Insurance Coverage Adequacy, Health Policy, Health System, Hospital, Hospital Industry, Medicaid, Medicaid Expansion, Medical Loss Ratio (MLR), Out of Pocket Expenses, Preexisting Conditions, Prescription Drugs, Preventative Care, Uncompensated Care, Underinsured, Uninsured • Leave a comment

https://news.bloomberglaw.com/pharma-and-life-sciences/health-agency-preparing-for-lapse-in-extra-obamacare-subsidies?mkt_tok=ODUwLVRBQS01MTEAAAGDWuGQisFiXP1YU7ldhH-D-v-Qezz0Y7Ol85lQV_EWybFJCX5nhwm1xijPeqwqKvJ4KM_KHbGLJ6Tq5fpqr7aHTFGKPLChP3FMmQbI5dZoOR8W

  • Obamacare enrollment at a record-high 14.5 million
  • Congress may not fund premium subsidies in 2023

The Affordable Care Act marks its 12th anniversary Wednesday, and despite a record 14.5 million enrollees, the Biden administration is preparing for the possibility that millions could lose coverage next year.

The $1.9 trillion pandemic stimulus package (Public Law 117-2), signed March 2021, reduced Obamacare premiums to no more than 8.5% of income for eligible households and expanded premium subsidies to households earning more than 400% of the federal poverty level. The rescue plan also provided additional subsidies to help with out-of-pocket costs for low-income people. As a result, 2.8 million more consumers are receiving tax credits in 2022 compared to 2021.

But without congressional action, the subsidies—and the marketplace enrollment spikes they ushered in—could be lost in 2023. A new HHS report released Wednesday, shows an estimated 3.4 million Americans would lose marketplace coverage and become uninsured if the premium tax credits aren’t extended beyond 2022.

In a briefing with reporters Tuesday, Chiquita Brooks-LaSure, administrator for the Centers for Medicare & Medicaid Services, said her agency is “confident that Congress will really understand how important the subsidies were” to enrolling more people this year. The CMS would “pivot quickly,” however, to implement new policies and outreach plans if the subsidies aren’t extended as open enrollment for 2023 begins in November.

“That said, today and tomorrow we are celebrating the Affordable Care Act,” Brooks-LaSure added. “As part of that process, we’ve been reminding ourselves that sometimes it takes some time to pass legislation. And just like the Affordable Care Act took time, we’re confident that Congress is going to address these critical needs for the American people.”

After years of legal and political brawls that turned the landmark legislation into a political football, Obamacare “is at its strongest point ever,” Brooks-LaSure said. The 14.5 million total enrollees—those who extended coverage and those who signed up for the first time—is a 21% increase from last year. The number of new consumers during the 2022 open enrollment period increased by 20% to 3.1 million from 2.5 million in 2021.

This week, the Department of Health and Human Services will highlight the impact of the ACA and the Biden administration’s efforts to strengthen the law. The CMS recently announced a new special enrollment period opportunity for people with household incomes under 150% of the federal poverty level who are eligible for premium tax credits. The new special enrollment period will make it easier for low-income people to enroll in coverage throughout the year.

Troubled times could be around the corner, however, as millions of people with Medicaid coverage could become uninsured after the public health emergency ends. Under the Families First Coronavirus Response Act (Public Law 116-127), signed March 2020, states must maintain existing Medicaid enrollment until the end of the month that the public health emergency is lifted. Once the continuous enrollment mandate ends, states will resume Medicaid redeterminations and disenrollments for people who no longer meet the program’s requirements.

Dan Tsai, deputy administrator and director of the Center for Medicaid and CHIP Services at CMS, said the agency is working with states to make sure people who lose Medicaid coverage can be transferred into low- and no-cost Obamacare coverage.

“A substantial portion of individuals who will no longer be eligible for Medicaid will be eligible for other forms of coverage,” including marketplace coverage, Tsai told reporters Tuesday.

In a statement, President Joe Biden acknowledged the law’s great impact. “This law is the reason we have protections for pre-existing conditions in America. It is why women can no longer be charged more simply because they are women. It reduced prescription drug costs for nearly 12 million seniors. It allows millions of Americans to get free preventive screenings, so they can catch cancer or heart disease early—saving countless lives. And it is the reason why parents can keep children on their insurance plans until they turn 26.”

The Affordable Care Act: Twelve Years and Nine Lives Later

Posted on by • Posted in ACA, Bad Debt Expense, Deferred Healthcare, Health Insurance Coverage Adequacy, Health Policy, Health System, Hospital, Hospital Industry, Medical Loss Ratio (MLR), Out of Pocket Expenses, Preexisting Conditions, Supreme Court, Uncompensated Care, Underinsured, Uninsured • Leave a comment

http://healthaffairs.activehosted.com/index.php?action=social&chash=de905148259ea27fa49e2303ef2e0017.5360&s=a9eec07a130d7809d93928ad264a482b

A new spring brings another anniversary of the Affordable Care Act. Twelve (sometimes tumultuous) years later, this remarkably resilient law is on firmer ground than ever before.

So what are some highlights?

The uninsured rate remained stable even in the face of a global pandemic. Congress leveraged parts of the ACA to quickly cover COVID-19 tests and vaccines without cost sharing.

The American Rescue Plan Act supercharged marketplace subsidies, leading to record-high marketplace enrollment.

And there are currently no existential legal threats to the law working their way through federal courts.

In some ways, this rosy report feels unremarkable. Why expect otherwise with the law now in place for more than a decade and baked into every part of the health care system?

But this outcome was far from inevitable.

Just five years ago, Congress tried to repeal as much of the law as possible. When those broader efforts failed, Congress eliminated the much-maligned individual mandate penalty. We appeared to have reached a stalemate: Democrats could not improve the law while Republicans could not repeal it.

Could this be the moment we moved on from ACA politics?!

Enter the courts. In early 2018, Republican attorneys general sued to invalidate the mandate and, with it, the rest of the law. That lawsuit—California v. Texas—was ultimately heard by a new Supreme Court one week after the 2020 election, and the ACA was upheld just last summer.

This marked the third time that the Supreme Court largely rebuffed what could have been a crippling legal challenge to the law. It feels like ancient history now, but it is worth remembering that we were still playing “will they or won’t they?” with the Supreme Court and ACA only one year ago.

In the meantime, the Trump administration tried to undermine access to coverage under the law—except when it didn’t. I won’t list all the relevant Trump-era policies, but they had an impact: the uninsured rate rose, and marketplace enrollment declined until the 2021 plan year.

Ironically, one policy meant to destabilize the market had the opposite effect: so-called “silver loading” led to more generous marketplace subsidies and likely helped stave off even greater coverage losses.

This is the recent history that is top of mind as I reflect on the year ahead—and the work left to do to achieve universal coverage. Here are just some of the major issues facing policymakers:

     • The clock is ticking to extend the American Rescue Plan Act subsidies. If Congress fails to do so, millions will face premium hikes next year and marketplace enrollment will likely drop.

     • More than 2 million low-income people remain stuck in the Medicaid coverage gap in the 12 states that have not yet expanded their Medicaid program.

     • Up to 15 million people, including nearly 6 million children, could lose Medicaid coverage at the end of the COVID-19 public health emergency.

     • There is increasingly an affordability and underinsurance crisis, including for those with job-based coverage: an estimated 87 million people were underinsured in 2018.

Congress and the White House are working to address these challenges, but much uncertainty remains.
“It feels like ancient history now, but it is worth remembering that we were still playing ‘will they or won’t they?’ with the Supreme Court and Affordable Care Act only one year ago.” – Katie Keith

Looking beyond Congress, 2022 will be an important year for regulatory changes. The Biden administration has proposed, but has not yet finalized, major marketplace changes. Other already-identified priorities include fixing the family glitch, limiting short-term limited duration insurance, and enhancing nondiscrimination protections. We could see movement on at least some of these rules soon.

While the Biden administration may be waiting out Congress before initiating some rulemaking, time is of the essence. New rules take many months to adopt and then take effect—followed by more time to deal with the legal challenges that typically follow.

Follow along as I dive deep on these issues and more in a new Health Affairs’ Health Reform newsletter.

We’ll highlight the latest health policy developments—from legislation to litigation—and explain what these changes mean for patients, payers, providers, and other key health care stakeholders.
It’s Your Birthday, Affordable Care Act!
In March 2020, Health Affairs published a theme issue to celebrate the tenth anniversary of the Affordable Care Act. The issue contains many illuminating research articles on the landmark legislation, from its impact on “the cost curve” to Medicaid expansion.

Above is a datagraphic from the issue showing how the ACA affected insurance coverage.