ARTICLE: Medicare and Medicaid, the Affordable Care Act, and US Health Policy Ho

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ARTICLE:

Medicare and Medicaid, the Affordable Care Act, and US Health Policy

Howard Bauchner, MD

In 1965, Medicare and Medicaid transformed health care in the United States. Elderly, poor, and disabled individuals were guaranteed health insurance coverage, and with it access to physicians, hospitals, other services, and important advances in medicine. Almost 50 years later, the Affordable Care Act (ACA) was introduced with the intent to ensure that all Americans are guaranteed health insurance coverage and with it access to a similar set of services. Although the introduction of Medicare and Medicaid was contentious and met with skepticism by many, including physicians, ultimately it became embedded in US society. Whether the same will be true for the ACA remains unclear. This theme issue of JAMA is dedicated to recognizing 50 years of Medicare and Medicaid. Medicare and Medicaid are huge programs. In a detailed comprehensive review of these programs, Altman and Frist1 describe both programs and how they have evolved over the last 5 decades. Currently, Medicare covers 55 million individuals and costs $585 billion; Medicaid covers 66 million individuals and costs $449 billion. Together these programs insure 111 million people, or 1 in 3 individuals in the United States. Whereas Medicare is a federal program, Medicaid is a shared responsibility of federal and state governments. At least for the foreseeable future and based on current assumptions, Medicare is financially stable, although these financial projections change every few years. The financial well-being of Medicaid is more of a challenge. Although the ACA (and the federal government) will support Medicaid expansion for the next few years, Medicaid now accounts for up to one-third of the budgets of some states, and given emerging new technologies and therapies, restraining the increase in health care costs will be a challenge. Ascribing beneficial effects to health insurance has always been fraught with difficulty because few true experiments have ever been conducted. Nevertheless, most people would prefer to have health insurance. In a review of the Medicare-eligible population over the past 15 years, Krumholz and colleagues2 describe numerous changes. Overall mortality among Medicare beneficiaries has declined from 5.30% in 1999 to 4.45% in 2013. There has also been a decline in the total number of hospitalizations per 100 000 person-years and a decrease in mean inflation-adjusted inpatient expenditures per Medicare fee-for-service beneficiary. Encouragingly, in the last 6 months of life, the number of hospitalizations, the percentage of beneficiaries with 1 or more hospitalizations, and the more recent data on inflation-adjusted inpatient expenditures have also declined. These data suggest that end-of-life care in the United States may be changing. The ACA has expanded health care coverage in the United States. Numerous reports indicate that between 12 million and 15 million individuals have been newly insured. Sommers and colleagues3 analyzed data collected between January 2012 and January 2015 from more than 500 000 adults who participated in the continuously fielded daily Gallup-Healthways Well-being Index. They found that compared with the pre-ACA trend, the adjusted uninsured rate decreased 7.9 percentage points following implementation of the ACA. In addition, there were decreases in the percentage of respondents reporting lack of a personal physician, lack of easy access to medicine, and inability to afford care and decreases in the proportion of those reporting fair or poor health. Improvement in coverage was largest among minority groups; for example, the decrease in the uninsured rate was 11.9 percentage points among Latino adults and 10.8 percentage points among non-Latino black adults. Because of the size of the sample, the authors were also able to analyze the differences in the 28 states and District of Columbia that expanded Medicaid and 22 states that did not. The uninsured rate declined in all states, but a difference-indifference analysis showed a greater reduction in the states that expanded Medicaid, with an overall decline of 5.2 percentage points. The ACA is successfully meeting one of its goals, extending health care to more Americans. A major goal of the Centers for Medicare & Medicaid Services is to incentivize high-quality care. In an analysis of the Hospital-Acquired Condition Reduction Program that reduces payments to hospitals that perform poorly on various measures, Rajaram and colleagues4 found that hospitalizations were more likely to be penalized if they were accredited by the Joint Commission, were a major teaching hospital, cared for patients with complex injury or illness, and were a safety-net hospital. In addition, on an externally validated summary measure of hospital quality, they found that hospitals with the highest-quality scores were significantly more likely to be penalized than hospitals with lowest-quality scores (67.3% vs 12.6%). These data highlight how difficult it is to assess the quality of hospital care and show that the measures used by the Hospital-Acquired Condition Reduction Program may not be appropriate. Given that measuring quality is a centerpiece for many of the initiatives of the CMS and that a substantial amount of reimbursement is at risk, more work may be needed to validate measures of quality. Opinion EDITORIAL Editorials represent the opinions of the authors and JAMA and not those of the American Medical Association. jama.com (Reprinted) JAMA July 28, 2015 Volume 314, Number 4 353 Copyright 2015 American Medical Association. All rights reserved. Downloaded From: http://jamanetwork.com/pdfaccess.ashx?url=/data/journals/jama/934258/ by a Lehman College User on 04/24/2017 Copyright 2015 American Medical Association. All rights reserved. Nine scholarly Viewpoints in this issue of JAMA discuss various aspects of current US health care policy. Gostin and colleagues5 report on the recent King v Burwell decision, the initial goals of the ACA, the various legal challenges, what the ACA has accomplished, and remaining challenges focusing on further increasing coverage for the near poor, poor, and undocumented immigrants. Butler,6 Cutler,7 and Wilensky8 provide insightful perspectives and suggestions about how the ACA should be modified to be successful. As discussed by Altman and Frist,1 Medicare and Medicaid have constantly evolved since 1965. Clough and colleagues9 describe emerging alternative payment models in fee-for-service Medicare. Mann and Osius10 and Bindman11 reflect on Medicaid, reviewing its current status and future challenges. Boozary and Senators Manchin and Wicker12 argue that the CMS should consider socioeconomic status when calculating penalties related to readmissions because safety-net hospitals are being unfairly penalized. Hwang and colleagues13 review many of the important innovations that have begun at the state level; for example, Maryland has eliminated fee-forservice payment to hospitals and Arkansas and Tennessee are experimenting with bundled payments. This type of “local” innovation in health care delivery maybe more acceptable than policy dictated in Washington. One of the remarkable aspects of the United States is the ability to innovate, and this is generally true in most aspects of society, including health care. Although the US has lagged behind other resource-rich nations in extending health care to all of its citizens, the ACA, Medicaid expansion, and other health care delivery models represent creative and innovative ways to try to accomplish this goal. The future of health care delivery in the United States faces many challenges, as frequently discussed in other Viewpoints and other articles that regularly appear in JAMA. The commitment of moving from volume-based reimbursement to value-based reimbursement should continue. Diagnostic and therapeutic advances must be available to everyone and not exacerbate but rather ameliorate health care disparities. Endof-life care should be transformed and be more patient focused. (Sadly, most physicians have their own personal stories of how the health care system has failed their own family members at end of life.) Reducing waste and inappropriate care is critical so that those savings can be used to support new therapies, many of which will be expensive. The qualityimprovement movement needs to be reinvigorated by parsing the number of measures and focusing on those that are likely to lead to the largest gains in health. The spirit of professionalism that has so long served physicians well must be recaptured. And the administrative burden on practicing physiciansmust be reduced so that they can spendmore time communicating with their patients and providing patientcentered care. Just as Medicare and Medicaid have evolved over the past 50 years to become critically important and indispensable elements of the health care system, the ACA must continue to evolve. Both political parties appear to be committed to ensuring that all Americans have access to health care—be that as a right or as a privilege. Legal and political challenges to the ACA will continue. They are an inevitable part of the US political landscape, but challenges to the ACA must be accompanied by other ideas that will ensure that all Americans have access to high-quality, affordable, health care.

QUESTION:

From a financial standpoint, would you consider programs like Medicaid and Medicare to be cost-effective? Provide at least one source (APA format) that supports your point, and a recommendation to improve these programs.

Explanation / Answer

Programs like Medicaid and Medicare have little incentive to consider their long-term implications, however shared savings programs offer physicians a chance for financial gain.

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