Obama JAMA Article Documents Success of Affordable Care Act

Add another achievement to President Barack Obama’s list of remarkable accomplishments. Our President this week became the first sitting President to publish a scholarly article. President Obama penned “United States Health Care Reform: Progress to Date and Next Steps” for the Journal of the American Medical Association. The article includes 68 citations, more actual reliable sources than the Republican nominee for President has made in the last twelve months.

Grouches in the comment section will quibble that the President’s article did not undergo the peer review that marks truly scholarly articles. However, JAMA says this “special communication… went through a two months of fact-checking and multiple edits and revisions.” This paper is no Donald Trump speech.

The President’s article includes six charts:

Percentage of Individuals in the United States Without Health Insurance, 1963-2015
Percentage of Individuals in the United States Without Health Insurance, 1963-2015
Decline in Adult Uninsured Rate From 2013 to 2015 vs 2013 Uninsured Rate by State
Decline in Adult Uninsured Rate From 2013 to 2015 vs 2013 Uninsured Rate by State
Percentage of Workers With Employer-Based Single Coverage Without an Annual Limit on Out-of-pocket Spending
Percentage of Workers With Employer-Based Single Coverage Without an Annual Limit on Out-of-pocket Spending
Out-of-pocket Spending as a Percentage of Total Health Care Spending for Individuals Enrolled in Employer-Based Coverage
Out-of-pocket Spending as a Percentage of Total Health Care Spending for Individuals Enrolled in Employer-Based Coverage

The President says his plan is saving money:

As a result, health care spending is likely to be far lower than expected. For example, relative to the projections the Congressional Budget Office (CBO) issued just before I took office, CBO now projects Medicare to spend 20%, or about $160 billion, less in 2019 alone.41,42 The implications for families’ budgets of slower growth in premiums have been equally striking. Had premiums increased since 2010 at the same mean rate as the preceding decade, the mean family premium for employer-based coverage would have been almost $2600 higher in 2015.33 Employees receive much of those savings through lower premium costs, and economists generally agree that those employees will receive the remainder as higher wages in the long run.43 Furthermore, while deductibles have increased in recent years, they have increased no faster than in the years preceding 2010.44 Multiple sources also indicate that the overall share of health care costs that enrollees in employer coverage pay out of pocket has been close to flat since 2010 (Figure 545– 48), most likely because the continued increase in deductibles has been canceled out by a decline in co-payments [President Barack Obama, “United States Health Care Reform: Progress to Date and Next Steps,” Journal of the American Medical Association, 2016.07.11].

…and saving lives:

At the same time, the United States has seen important improvements in the quality of care. The rate of hospital-acquired conditions (such as adverse drug events, infections, and pressure ulcers) has declined by 17%, from 145 per 1000 discharges in 2010 to 121 per 1000 discharges in 2014.49 Using prior research on the relationship between hospital-acquired conditions and mortality, the Agency for Healthcare Research and Quality has estimated that this decline in the rate of hospital-acquired conditions has prevented a cumulative 87 000 deaths over 4 years49[Obama, 2016.07.11].

To save more money and more lives, President Obama recommends offering a public option in underserved markets:

…[T]he majority of the country has benefited from competition in the Marketplaces, with 88% of enrollees living in counties with at least 3 issuers in 2016, which helps keep costs in these areas low.57,58 However, the remaining 12% of enrollees live in areas with only 1 or 2 issuers. Some parts of the country have struggled with limited insurance market competition for many years, which is one reason that, in the original debate over health reform, Congress considered and I supported including a Medicare-like public plan. Public programs like Medicare often deliver care more cost-effectively by curtailing administrative overhead and securing better prices from providers.59,60 The public plan did not make it into the final legislation. Now, based on experience with the ACA, I think Congress should revisit a public plan to compete alongside private insurers in areas of the country where competition is limited. Adding a public plan in such areas would strengthen the Marketplace approach, giving consumers more affordable options while also creating savings for the federal government 61 [Obama, 2016.07.11].

Brave and realistic Democrats like Rep. Paula Hawks and Jay Williams who are willing to embrace the Obama Administration’s successes may not want to cite all 68 of the President’s footnotes in their stump speeches. But they could use the President’s assessment of Republicans’ harmful hypocrisy and obstructionism over the Affordable Care Act:

Republicans reversed course and rejected their own ideas once they appeared in the text of a bill that I supported. For example, they supported a fully funded risk-corridor program and a public plan fallback in the Medicare drug benefit in 2003 but opposed them in the ACA. They supported the individual mandate in Massachusetts in 2006 but opposed it in the ACA. They supported the employer mandate in California in 2007 but opposed it in the ACA—and then opposed the administration’s decision to delay it. Moreover, through inadequate funding, opposition to routine technical corrections, excessive oversight, and relentless litigation, Republicans undermined ACA implementation efforts. We could have covered more ground more quickly with cooperation rather than obstruction. It is not obvious that this strategy has paid political dividends for Republicans, but it has clearly come at a cost for the country, most notably for the estimated 4 million Americans left uninsured because they live in GOP-led states that have yet to expand Medicaid.65 [Obama, 2016.07.11].

President Obama’s JAMA article makes clear that the Affordable Care Act has done good things for our country. Instead of fantasizing about erasing President Obama’s historic legacy, Congress should focus on building on the ACA’s success.


17 Responses to Obama JAMA Article Documents Success of Affordable Care Act

  1. I was pretty skeptical of the affordable care act at first, largely because while more people were insured as a part of the process, many were getting the cheapest insurance plans they could, which often had astronomical deductibles, tiny networks of coverage and really high out of pocket annual ceilings. My thought, and the thought of many in the Sioux Falls area involved in health care, was that charity care wouldn’t decrease all that much because poor people, who are typically sicker and more likely to use expensive emergency care, still wouldn’t be able to pay their medical bills because of garbage insurance plans. It turned out that charity care did go down, and while medicaid payment shortfalls increased, the decrease in charity care more than covered the gap. I’ll quote and link a piece produced by Ascension Health, the largest non-profit health care system in the US. http://kff.org/health-reform/issue-brief/how-are-hospitals-faring-under-the-affordable-care-act-early-experiences-from-ascension-health/

    Looking at particular cost items, charity care costs decreased 40.1 percent among hospitals in Medicaid expansion states compared to 6.2 percent in non-expansion states. However, another component of cost of care to the poor, Medicaid shortfalls – the difference between what Medicaid pays and the costs of treating Medicaid patients – increased 31.9 percent between 2013 and 2014. Shortfalls increased for hospitals in expansion states but were more than offset by increases in Medicaid revenue. Shortfalls increased more among hospitals in non-expansion states than expansion states and were not offset by increases in Medicaid revenue, possibly due to state cuts in provider reimbursement. Combining the decrease in charity care costs with the increase in Medicaid shortfalls, the net cost of caring for low income patients decreased among hospitals in expansion states, while these costs increased among hospitals in non-expansion states.

    On the payer side, however, things aren’t quite so rosy (http://www.huffingtonpost.com/entry/obamacare-enrollees-are-sick_us_56face7be4b0143a9b497571). Those coming to the exchanges for insurance are consistently more unhealthy (no —-, people who had to avoid health care for a long time due to no insurance are sick), and it is destabilizing the marketplace. Insurers are consistently in the red and many are bailing or failing. At this point, single payer feels almost inevitable. Some would argue that would be awesome and amazing and super, but I am not so sure.

  2. mike from iowa

    The ACA isn’t perfect. How much better could it have been with some wingnut input and cooperation? How much better could it have been without total obstructionism?

    We could get rid of it and let all those uninsured people go back to frequenting emergency rooms and letting taxpayers pick up the exorbitant costs. That oughta work.

  3. After ACA my premiums rose as we had to raise deductibles and copay and a subpar perscrition plan. Go ahead and toot your horn all you want, it hasn’t worked out for many. Those are the undisputed facts.

  4. Does many equal most, in your opinion, Greg?

  5. Don Coyote

    @Lost In Iowa: “The ACA isn’t perfect. How much better could it have been with some wingnut input and cooperation? How much better could it have been without total obstructionism?”

    1) The “public option” as touted by many Democrats during the legislative debate was finally dropped because of the “obstructionism” of a single Democrat Senator, Joe Lieberman.

    2) ACA only survived judicial review because of Chief Justice Roberts’ transmogrification of the unconstitutional individual mandate into a tax on not owning health insurance. The Republicans had claimed that the individual mandate was unconstitutional during legislative debate and were proven right.

    3) Since the individual mandate has been declared a tax, it begs the question on how a tax can originate in the Senate when the Constitution is clear that all taxation legislation has to originate in the House.

    Obama’s ACA was a hash of legislative blunders owned entirely by the Democrats.

  6. Steve Sibson

    “Obama’s ACA was a hash of legislative blunders owned entirely by the Democrats.”

    And the same can be said about South Dakota’s legislature. Clearly the benefit went to Sanford and Avera and represents the bipartisan nature of crony capitalism.

    It also benefits those wealthy enough to retire early and not wait until they reach 65 to get government healthcare by providing them with a tax cut.

  7. The Accountable Care Organization concept that was part of the ACA is another provision which will reduce cost in the long-term. The concept is a health care system becomes “responsible” for the individuals that regularly seek care within their organization, and if they are able to reduce their health care expenditures through use of proper care mechanisms, such as outpatient and preventative care, then Medicare (or the private insurance company) shares some of these cost savings with the ACO. In its early steps, it has seemed to be a good way to incentivize health care organizations to reduce admissions, improve care coordination, and explore an expanding home care system.

    While I carry a great deal of hope in the ACO concept to help rescue the ACA, I am still working in the midst of the chaos that is the first couple years. Health care organizations, including my own, are seeing exponential increases in the number of emergency department visits, while keeping a relatively constant rate of admissions (a marker of true emergencies). Organizations have been struggling to keep up, building huge emergency departments to manage the influx. Within my organization, we have seen a near doubling of emergency department visits, requiring us to double the size of our emergency department. Other SD hospitals I have heard of having 30+ people waiting in the waiting room at any given time. Hopefully this starts to tip in a different direction before our employees and providers burn out on giving clinic care.

    Luckily, there is hope.

  8. Dicta, given the problem of new patients joining the covered ranks and bringing in their long-untended maladies fade over time as we get to universal coverage and thus have fewer sick people delaying treatment?

  9. Greg, also undisputed: I can now get and keep health insurance. No rescission. Disputable: I’m likely paying less than I would have under the pre-ACA status quo of rising premiums.

  10. Dicta, if you’re not so sure about the awesome superness of single-payer, how about we try Obama’s plan, public option offered in the currently non-competitive Marketplaces? Let people choose between private and public coverage and see if they vote with their wallets for practical single-payer.

  11. mike from iowa

    Clueless in wherever the hell you come from- How much better could it have been without total obstructionism?”

    Exactly how many of the 39 wingnuts in the senate that voted against the ACA, actually voted for it? The answer is zero. TOTAL OBSTRUCTIONISM.

    Ben Nelson and other conservative dems threatened to filibuster the public option-not just Joe Lieberweenie.

  12. “Dicta, given the problem of new patients joining the covered ranks and bringing in their long-untended maladies fade over time as we get to universal coverage and thus have fewer sick people delaying treatment?”

    That’s kinda the million dollar question, and I admit that I am not sure. As MD noted upthread, Emergency Departments are still seeing people using their services as a surrogate for doctor’s appointments, so I think much of success in the sector depends on changing human behavior and habits. Common sense would support your point, and I hope it works out that way. It hasn’t yet, but managing chronic conditions is a long game and we have to keep that in mind. We’ll see.

    “Dicta, if you’re not so sure about the awesome superness of single-payer, how about we try Obama’s plan, public option offered in the currently non-competitive Marketplaces? Let people choose between private and public coverage and see if they vote with their wallets for practical single-payer.”
    Perhaps. My concern is twofold:

    1) Perceived leverage of public options considering the massive power of CMS. If there is a perceived chance of punishment by CMS for hospitals attempting to leverage higher payouts on a public option, the playing field isn’t level and completely tilts in favor of the government.
    2) This is the one that really concerns me: how do you have a player in a supposedly free market that is also that market’s regulator?

  13. Cory if ACA worked in your favor, good for you. The fact of the matter is that it didn’t work out that way for everyone.

  14. wow, how can daugaard sit in the governor’s chair with any kind of conscience, 5 years later, 30-90 unnecessary resident deaths per year at his feet?

    “through inadequate funding, opposition to routine technical corrections, excessive oversight, and relentless litigation, Republicans undermined ACA implementation efforts. We could have covered more ground more quickly with cooperation rather than obstruction. It is not obvious that this strategy has paid political dividends for Republicans, but it has clearly come at a cost for the country”.

    this should be a mantra in this election and in denny’s next move. like a bush war criminal he is.

  15. thx for your info, MD

  16. As an aside, there should be some irony in the logic of the health care system. For the amount that we pay for Medicare and Medicaid, we could provide high quality care to every American similar to fellow OECD countries.
    We could keep choice and avoid excessive care, instead, we continue to be fragmented and filled with administrative and regulatory bloat. Fortunately, that should bode well for my career choice in administration.
    It would seem to me that both conservative and liberal logic when it comes to health care would be to opt for a system that could cover everyone most affordably. Unfortunately, the logic of the drug companies, accrediting bodies, device manufacturers, health care systems, health care providers, etc does not. Unfortunately for taxpayers everywhere, popular opinion does not win out to a strong, organized, and influential lobby.

    In my current front-line employment, it is depressing when one witnesses the waste, over treatment, and lack of transparency we run into on a daily basis. Of course the reasons are always multi-factorial but, I cringe every time I provide care that I would not want my family, friends, or enemies to receive. The victims of the system.
    It would seem that further reform could be focused towards addressing the lack of transparency by developing a system for individuals to make true informed consent through financial transparency. I would argue that a person cannot make an ethical informed consent without being aware of the cost of the care. Many procedures, unnecessary workups, and other bloat could be avoided by allowing people to see the true cost of their care. I

  17. Roger Cornelius

    Anyway, congratulations to our president for another prestigious accomplishment.