Exploring the Less-Obvious Issues of an Affordable Care Act Repeal
The availability and use of Obamacare insurance coverage has almost doubled the utilization of substance abuse treatment in the Philadelphia region, according to the Chief Medical Officer of Independence Blue Cross.
Speaking to a gathering of reporters at a panel discussion organized by the Philadelphia Inquirer and the Association of Health Care Journalists, insurance executive Richard Snyder, said he was "personally proud" that those costs had gone up. Pointing to those statistics as one of the less obvious things that have come from the Affordable Care Act, he expressed concern about what a rollback of such benefits might mean.
"We know we have a massive problem of opiate abuse," Snyder said. "Nearly 900 people lost their lives in Philadelphia this past year as a result of opioid abuse. I don't know how bad it would have been if those who accessed care would not have had access to that care."
The bulk of the individuals receiving substance abuse treatment were from the population of people younger than 26 that the ACA allowed to stay covered under their parents' insurance plans.
Briefing for journalists
Snyder was one of five top Philadelphia area health policy experts empaneled in an evening session aimed at briefing journalists on some of the less obvious potential implications of dismantling the health care reform law. The event occurred as both the new Congress and the Trump Administration took their first steps towards repealing the ACA.
Panelist Robert Field, PhD, JD, a Drexel Professor of both Health Care Management and Policy and Law, noted that most of the news stories and national debate have been focused on the ACA's insurance exchanges to the exclusion of other "hidden" parts of the law.
For instance, he pointed to the ACA provisions that created new regulations for employer insurance. These include the elimination of annual and lifetime caps on benefits, mandated coverage for autism, and a new appeal process for employees whose claims were turned down by an insurer.
Elsewhere in the workplace, the ACA established a right for women to breastfeed at work and requires employers to provide time and an appropriately clean and safe place for that.
Changes throughout hospitals
The ACA is driving changes in how health care delivery systems operate their businesses -- as examples, Field cited Accountable Care Organizations, bundled payments and penalties for readmissions.
"In other areas," Field said, "the ACA provides subsidies for small employers, funds the training of physicians and nurse practitioners, and requires premium rebates when an insurer's medical loss ratio limit is exceeded."
He also pointed out that one of the least known -- but very important -- areas of the ACA is a section of the law known as the Biologics Price Competition and Innovation Act (BPCI). It established an accelerated pathway to FDA approval for generic "biosimilar" versions of the new category of hi-tech, hi-cost "biologic" drugs.
"Three of these have already been approved and this pharmaceutical field is taking off," Field said. "Repeal would certainly disrupt the biological market."
Panelist David Grande, MD, MPA, an Assistant Professor at Penn's Perelman School of Medicine and Director of Policy at the Leonard Davis Institute of Health Economics (LDI) said one of the worries that keeps him awake at night is the fate of Medicaid.
Lost in the shuffle
"I think there has been so much attention to everything related to the marketplaces and exchanges that discussions about the Medicaid programs have gotten lost in the shuffle," said Grande.
"Medicaid is certainly in the crosshairs in terms of whether it will continue to exist in the form that it exists today, whether it will be shifted more heavily to the states, or whether populations that have benefited from creating a more universal income eligibility standard will be shifted over to the private insurance market. What happens to the Medicaid program matters a whole lot and impacts people who are some of the most vulnerable populations in our health care system."
Panelist Mark Pauly, PhD, -- the nationally renowned Wharton School health economist who pioneered several of the concepts upon which the ACA was based -- pointed out that news stories never mention that only three percent of the population acquires insurance through the ACA exchanges and that repeal will have little effect on health insurance acquisition beyond that group.
Pauly went on to say that he personally favors the ACA's central premise because "I figure it's going to cost me about two grand more in taxes but I thought that would buy me a clean conscience because the number of uninsured would be greatly reduced and that's what I've been worried about."
Panelist Scott Harrington, PhD, a Wharton School Professor of Health Care Management, suggested reporters pay closer attention to the details of ACA replacement proposals. He noted that the pre-existing condition exclusion that the ACA eliminated was a key political issue.
Harrington said that the "Better Way" replacement proposal favored by Speaker of the House Paul Ryan and HHS Secretary nominee Tom Price takes a different "continuous coverage" approach. It would enable people to purchase standard coverage with no pre-existing condition exclusions. But then, if consumers either did not buy insurance or did not continue to stay insured they'd face a different situation at a later date when they did try to purchase coverage.
"They would likely face insurance ratings based on health status and they might face exclusions and long waiting periods," Harrington said.
The safety net for such people would be a separate high risk pool system. That system would be funded by the individual states rather than by raising rates in the larger and completely separate continuous coverage market.
Harrington pointed out that "if that model is to be effective, you're going to need a lot of money. The latest reports say it might take $15 to $20 billion annually to make high risk pools at the state level functional."