ACA's biggest impact on health yet to be seen

Working in manufacturing for decades, 63-year-old Gerold Walker never really thought about health insurance until he lost his job. Walker, a resident of Orange County, Calif., was eligible for Medicaid until he started getting pension payments.

It was around that time that he was diagnosed with cancer.

“I didn’t know which way to go,” Walker said.

He turned to AltaMed Health Services, a community health center. They enrolled him in a qualified health plan offered by California’s health insurance marketplace created by the Affordable Care Act.

“They saved me from a whole lot of stress,” Walker said.

Since 2014, more than 20 million people have received some form of healthcare coverage through the ACA, according to the Center on Budget and Policy Priorities, a left-leaning think tank. The share of Americans who reported not going to a doctor due to cost concerns and skipping a prescription because they couldn’t afford it fell from 2010 to 2018.

“Without the ACA we would not have the resources to take care of the patients we get to see every day now,” said Dr. Efrain Talamantes, medical director of the Institute for Health Equity at Los Angeles-based AltaMed.

The law has helped other providers such as Sinai Health System, a safety-net system in Chicago. CEO Karen Teitelbaum said the increase in insured patients Sinai has seen through the ACA has allowed it to reinvest $10 million in expanding needed services like behavioral health.

Despite seemingly nonstop legal and legislative fights over the ACA—the U.S. Supreme Court will hear oral arguments this fall in a case that could ultimately determine the fate of the law—few can argue its impact—good or bad—on nearly every aspect of healthcare, from the development of financing reforms to offering incentives for innovative technologies.

But the ACA’s biggest impact has yet to be realized, perhaps because it was an unintended effect.

Many of the law’s provisions emphasized caring for the entire patient and as such was a predecessor of population health—an ambitious goal to care for communities as a whole. But the law failed to address what has been population health’s biggest hurdle: financial support. Programs like the ACA-established Prevention and Public Health Fund, which allocated $15 billion over 10 years to support primary-care efforts, have been constantly underfunded.

“The ACA in my opinion was a catalyst for important change, but generally focused unfortunately on the insurance piece,” said Rita Numerof, co-founder and president of a healthcare consulting firm. What’s missing, she said, was a way to elevate the role of primary care—often a catchall field of medicine that is largely underpaid.

Stakeholders contend the true legacy of the ACA may be the creation of a primary-care delivery system robust enough to meet both the clinical and nonclinical challenges of an evolving healthcare landscape.

“It’s been good overall,” said Dr. Ted Epperly, CEO of Family Medicine Residency of Idaho, a federally qualified teaching health center, who said dropping the uninsured rate and protecting essential benefits were the ACA’s most successful goals. “But what’s advanced over the past 10 years more slowly are reforms on the delivery side.”

For providers like Epperly, the ACA has come to symbolize more than a philosophical question over what, if any, role the government should play in ensuring healthcare access.

He said the health law has brought a measure of financial stability for his practice and provided a medical home for patients who would have previously gone to the doctor only for emergencies.

“It was just a free-for-all, capitalistic system,” Epperly said. “What was happening prior to the ACA was a have- and have-not system based on income and wealth.”

Epperly said expanded coverage, insurance market reforms, and related cost protections for patients seeking preventive care leveled the playing field across the industry. In 36 states and the District of Columbia, more people were made eligible for Medicaid and gained access to annual screenings.

The ACA promoted accountable care organizations and support for primary-care training, which gave providers incentives to take a more active role in managing population health. Those aspects of the ACA have been major drivers in a more coordinated approach toward care delivery. Primary care pushed wellness programs to avoid poor health outcomes, lengthier hospital stays and costly healthcare procedures.

“The Affordable Care Act really kind of pivoted the nation to recognizing the importance of primary care,” said Dr. Gary LeRoy, president of the American Academy of Family Physicians.

One of the law’s largest moves to increase access was the Community Health Center Fund, which allocated approximately $16 billion over 10 years to existing centers and to build new ones. As a result, nearly 10 million more people were served by those facilities over the past decade. From 2011 to 2015, community health centers saw a 11 percentage-point decrease in uninsured patients and a 13 percentage-point increase in patients covered by Medicaid in expansion states compared with states that didn’t expand Medicaid, according to a 2018 study published in Health Affairs. More than 1 in 6 Medicaid beneficiaries nationally use community health centers.

Community health centers often serve the most economically vulnerable and medically underserved patients and have played a key role in reducing ethnic and racial health disparities. The centers score lower than the national average for women having babies with low birth weight and above average for women getting preventive services such as mammograms.

AltaMed’s Talamantes said the ACA’s community health center grant funding, coupled with Medicaid expansion, gave the system the resources to become more integrated and add specialty services to its primary care.

AltaMed once was the top enroller of patients into health plans offered on California’s health insurance marketplace. He said many of those were Latino, Spanish-speaking patients who had never been insured.

That gave AltaMed providers a better understanding of the community’s needs and helped them address some of the root causes of the disparities they face. Now the system has made outreach a part of its mission through such programs as its community health worker initiative, which helps patients better manage their conditions.

As patients access care more frequently, they develop stronger relationships with healthcare personnel. Talamantes said those ties are essential for establishing trust, which raises the likelihood patients will adhere to the information they receive to better manage their health.

“Everything we develop and implement has a patient’s needs in mind,” Talamantes said.

However, the community health workers are not reimbursed by most federal or private payers.

Most health systems lack the resources to help financially vulnerable patients who must choose between paying the electricity bill or buying their medication, said Mel McNea, CEO of Great Plains Health, a 116-bed regional referral center based in Nebraska.

Instead of fronting the cost of these efforts and hoping for a return on investment, hospitals have largely not addressed the issue. A 2017 survey of 300 health systems and hospitals conducted by global consulting firm Deloitte found that while 88% of providers reported they screen patients for social needs, 72% reported that they had no dedicated funding to address their needs.

“Right now, I can get paid more if somebody is admitted, or if they get a battery of tests, or if they come in for an operation because they haven’t had the good care to prevent that operation on the front end,” said Sinai Health’s Teitelbaum.

Dr. Howard Koh, former HHS assistant secretary for health during the Obama administration, said the ACA was never viewed as a completed work but rather as the foundation.

“We felt we had to lead by example,” said Koh, now a professor of the practice of public health leadership at Harvard University’s T.H. Chan School of Public Health. Koh played a key role in overseeing the ACA’s implementation. “If we were going to do it at the federal level, that would signal to states and cities we were supportive of such efforts at the local level and wanted to coordinate those efforts.”

Numerof is frustrated at the idea that access alone results in better outcomes.

“While expanding Medicaid may be better than nothing, it still doesn’t address the underlying issues of real access—that is meaningful primary care at a local level and community-based solutions that go beyond traditional physical healthcare,” she said.

Federal regulators did establish some broader health targets like reducing health inequities in access and outcomes. Racial and ethnic minority groups have traditionally had less access to healthcare services compared to white Americans and have disproportionately been at higher risk for a range of chronic health conditions.

Under the ACA, offices of minority health were established within six HHS agencies in 2010, including the CMS, the Centers for Disease Control and Prevention, the Food and Drug Administration, and the Substance Abuse and Mental Health Services Administration to coordinate disparity reduction activities.

The ACA also redesignated the National Institutes of Health’s National Center on Minority Health and Health Disparities into the National Institute on Minority Health and Health Disparities to integrate all of the NIH’s minority health and health disparities research.

HHS adopted new standards for collecting demographic data under the ACA to improve tracking of health differences among various populations to better target effective interventions.

In 2011, HHS developed its first national strategic action plan to address racial disparities. However, while individuals belonging to minority groups benefited from the ACA coverage expansions, more than half of the 28 million individuals who were still uninsured in 2018 were people of color, according to the Kaiser Family Foundation.

Federal and state initiatives have attempted to address disparities for certain health conditions that often disproportionately plague people of color. The ACA’s public health fund and the CDC’s $103 million Community Transformation Grants Program have supported evidence-based projects to reduce diabetes, heart disease and HIV, and to improve maternal and infant health among minority populations.

In spite of those programs, even supporters concede the ACA’s broader goal of achieving health equity among all Americans remains elusive.

“Coverage isn’t everything,” said Dr. Georges Benjamin, executive director of the American Public Health Association. “In many ways, expanding coverage has exposed a lot of the underlying problems that we’ve had in the healthcare system.”

Despite the ACA’s effort to raise primary care’s profile, most providers remain in a financial system that rewards volume and penalizes efforts that target value through prevention and wellness since they’ll likely negatively affect revenue. “Population health requires a very different way of looking at how and where and who delivers care,” Numerof said.

Sinai Health on Chicago’s West Side struggles to employ a community-based approach because of its cost. It serves as the safety-net provider for the one of the city’s most impoverished neighborhoods—48% of Sinai’s patients are covered through Medicaid, while 8.8% are uninsured.

Last July, Sinai opened a 28-bed inpatient crisis-stabilization behavioral health unit to provide short-term, 24-hour access for chronic and acute psychiatric care.

Sinai has also expanded its Asthma Care Partners program, which since 2001 has integrated standard clinical-care delivery with the use of community health workers who visit patients’ homes to better manage their conditions.

Asthma rates in Chicago are higher than the national average, affecting 1 in 5 adults residing in three of the neighborhoods closest to Sinai. Since its inception, the Asthma Care Partners program has been credited with reducing ED visits by 75%, days in the hospital by 80% and urgent-care clinic visits by 91% among its participants.

That program relied on grant funding, philanthropic sources and self-funding.

“We have to start formulating how to reward for keeping people healthy so that everybody wins,” Teitelbaum said.

Since 2014 and as a result of the ACA, all not-for-profit hospitals have been required to conduct a community health needs assessment every three years and implement a strategy to meet those needs.

The impact of that requirement has gotten mixed reviews. Last May, the American Hospital Association estimated that not-for-profit hospitals provided $95 billion in community health benefits in 2016, and concluded that to be 11 times greater than the value of tax revenue that would have been collected from those hospitals if they were not tax exempt.

But a 2019 study published in the journal Population Health Management stated the community health needs assessment in its current form made it difficult to get meaningful data on how those interventions affected outcomes. Koh said the assessments have forced many providers to recognize the importance of social determinants of health.

“The future of public health is having hospitals going beyond their walls and engaging more with the communities to address social determinants,” Koh said.

Great Plains Health’s McNea said his facility has yet to experience the full impact of the ACA in terms of coverage expansion. In 2018 Nebraska voters approved a ballot measure to expand Medicaid, but it isn’t set to go into effect until Oct. 1. 

“I think that the ACA started this awareness of population health that is continuing to build,” McNea said.

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