The First Five Years of the ACA in Review

This article is the second of a two part series. See article one .

Cost of Care: The ACA encouraged the creation of (ACOs) to integrate and coordinate patients’ health care experiences. Under the Medicare Shared Savings Program (MSSP), providers who create ACOs and meet quality metrics are eligible to share in part of the savings. There are currently 405 ACOs participating in the MSSP, serving 7.2 million Medicare beneficiaries and saving approximately $700 million while improving quality measures and care experiences. Some ACOs have also joined the Pioneer Program, where providers not only share in savings but also expenses. These programs have saved $385 million within their first 2 years.

Through its variety of innovations, the ACA has decreased monthly Medicare expenditures per beneficiary by 2% ($14) and significantly reduced ED visits and inpatient hospitalizations.

From 2010 to 2013, US annual health care expenditures per capita dropped from 5.6% to 2.3% and health care spending has stabilized at approximately 17% of GDP. This has caused the Congressional Budget Office to reduce its projected Medicare spending for 2020 by more than $200 billion (20%).

Quality of Care: In an effort to decrease readmission rates, Medicare began to issue financial penalties to hospitals with higher-than-expected rates of , resulting in 150,000 (>1%) fewer readmissions. It has been argued, however, that these penalties unfairly target safety net and large teaching hospitals. Medicare has also begun to issue penalties to hospitals when ‘never-events’ occur, cutting 1% of payments to those hospitals in the lowest quartile of safety performance. This initiative contributed to the first-ever documented decrease (17%) in hospital-acquired conditions nationally, saving an estimated 50,000 lives and $12 billion.

Not all Roses: Though there are been many successes, the first five years of the ACA have not been perfect. The Marketplace websites debuted with many technical issues. Many Americans were surprised to find that their private health plans had been cancelled because they did not meet the ACA’s minimum standards. Some worried that Marketplace plans restricted access to providers, though there has not been a major outcry over this provision.

Significant press has been directed toward one unintended effect of the Marketplaces: Under threat of financial penalties for remaining uninsured, many Americans have signed up for so called ‘Catastrophic’ health plans with substantial deductibles and copayments in order to minimize premiums.

commentary by Vidya Eswaran

Abstract

Just over 5 years ago, on March 23, 2010, President Barack Obama signed the Affordable Care Act (ACA) into law. Its enactment may constitute the most important event of the Obama presidency and could fundamentally affect the future of health care in the United States. From a historical perspective, 5 years is a very short time, far too short to assess definitively the effects of the ACA. Still, the 5-year mark seems to be a logical point to pause and take stock of how the ACA has fared to date – to review what we know now of its effect. PMID: 25946142.

Blumenthal, D. et al. N Engl J Med 2015; 372:2451-2458