“Disruption is Neither Good nor Bad”

“The ACA was a disruptive act. Disruption is neither good nor bad.  It is what we make of it.” 

–Richard Nathan

The popular media has mostly portrayed the Affordable Care Act as a piece of insurance expansion legislation, but many at the Academy Health “National Health Policy Conference” would argue differently.  In an exciting plenary session, Alice Rivlin, current Senior Fellow at the Brookings Institute proclaimed, “The ACA is a massive experiment in federalism.”  The reality is that the ACA provided states with tremendous flexibility to reform their delivery systems: Vermont (almost) switched to single payer, Indiana is moving forward with a “consumer-driven” approach, and Maryland will move to a global budgeting system.

Source: Peter Megyeri (Flickr/CC)

Source: Peter Megyeri (Flickr/CC)

Noam Levy, of the Los Angeles Times, predicts that in the future, the biggest story out the ACA may not be the insurance expansion, but instead the results of the interstate experiments in health care delivery systems.  Years down the road, the most interesting data may, in fact, be the variation from individual state reforms on healthcare spending and health outcomes.

Beyond large-scale delivery reforms, states are implementing smaller reforms that may prove to be just as insightful.  An excellent example announced at the conference was Oklahoma’s negotiations with the state’s tribal governments to collaborate on Medicaid coverage.

Indiana has announced it will attempt to define and discourage inappropriate emergency department visits through co-pays.

Finally, even if none of the state waiver experiments work out, the ACA has accelerated America’s transition away from traditional fee-for-service medicine to payment for quality medical care.  As CMS has already announced, their goal is for 90% of hospital payments to be linked to quality by 2018.  Granted, this is an ambitious goal that few health policy experts believe to be realistically achievable.  Nonetheless, the effort will have significant effects.

Between state-based reforms and CMS quality targets, the ACA creates an abundance of work for health policy researchers in the future.  A great deal of effort will be required to compare systems-level successes with failures regarding the many smaller reforms instituted in the era of health reform.  Ultimately, health policy researchers and perhaps the public will gauge the success or failure of specific ACA provisions

Time will tell if Maryland’s All-Payer model or Indiana’s emergency department utilization project will prove effective.

Perhaps even greater work will be needed on the quality side.  A panel devoted to the science of quality metrics ultimately ended with more questions than answers.  How do we develop a that incentivizes providers to act effectively and efficiency without causing provider neglect to unmeasured aspects of care? How do we incorporate patient’s goals into metrics? How do we address shifting patient needs for end-of-life care?

Ultimately, the policy community will need to provide answers to these complicated questions. Those answers will dramatically change .

commentary by Kyle Fischer, MD, MPH