What Researchers Don't Yet Know About The ACA
In his address as President of the American Society of Health Economists (ASHEcon), University of Pennsylvania economist Mark Pauly, PhD, emphasized his support for the Affordable Care Act but his concerns about the weak evidence on which some of that law's provisions are based.
Pauly, who is a Wharton School Professor of Health Care Management and a Leonard Davis Institute of Health Economics (LDI) Senior Fellow, was a keynote speaker at ASHEcon's 2016 Biennial Conference that took place on Penn's campus in June.
One of his points was that the current version of the ACA's insurance exchanges or marketplaces offer high-cost-sharing policies that may impede the broad population health goals the ACA was theoretically designed to achieve.
"The great majority of the people currently using exchanges have incomes low enough for subsidies and the great majority of them have chosen bronze and silver plans," Pauly said. "That may be a serious source of concern because in surveys many tell us that 'with this high out-of-pocket cost, I went without care I would have otherwise purchased.'"
"I think it's more than a rhetorical question to ask 'Should these low income people actually be allowed to to buy policies like the Bronze Plan with such high out-of-pocket payments?'," Pauly said.
He noted that the right answer to that question isn't currently known because "it depends ultimately on some empirical information that we don't have that might provide guidance to the policymakers we're trying to advise about how to ideally design the structure of policies offered on ACA exchanges."
Broad measures of health
"One thing we'd like to know," Pauly said, "is the marginal effectiveness of insurance-induced use on broad measures of health. We don't have very good evidence on this. We do have epidemiology evidence on small scale impacts of cost sharing but what we need to know for policy purposes is what does it do for the broad sweep of a health indicator."
"Another thing we need to know is perhaps the hardest of all: What value taxpayer/voters place on improved health from better coverage induced by the insurance subsidies they finance," he said.
Pauly said overall, the ACA "has a durable and rational qualitative structure which I think will survive the slings and arrows of the current political environment." But he noted his concern. "When the dust clears and we get back to a more normal political situation, will voter/taxpayers really be willing to support the kind of structure of the ACA or will there be pressure to change it?"
Health economists' obligation
He suggested that health economists had to do more to produce information to "specify and justify the ideal parameters of eligibility, subsidy and coverage. This is something we know how to do. We know how to estimate things like the effectiveness of insurance coverage at various levels for large populations in the aggregate. And we even know -- if we are willing to take a flyer on it -- how to estimate what taxpayers are willing to pay. We have an obligation to produce this kind of information and its our fault if we do not."
"Our biggest challenge," he told the audience, "is to produce evidence of the effect of care on health outcomes. Currently we can say almost nothing with confidence. Although, thank goodness that a bunch of states didn't expand Medicaid so at least we'll hopefully be able to use them as a control group to find out the effect of Medicaid coverage on use. Sometimes God works in mysterious ways."