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Bridge Michigan
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It’s time to move beyond current debate on Obamacare

The media seem to be finally united on one point about the Affordable Care Act: it is not going to be repealed.

The numbers tell the story: More than 8 million people—of whom 2.2 million are young adults between the ages of 18 and 34—selected a health plan through the Health Insurance Marketplace. Nearly five million more are now enrolled in Medicaid and the Children’s Health Insurance Program. And, millions more signed up for coverage directly through health plans. In Michigan, more than 272,000 people selected a Marketplace health plan and more than 269,000 have enrolled in the state’s expanded Medicaid program since enrollment began April 1.

While pundits seem to agree that the law is not going to be repealed, the ACA continues to figure heavily in many midterm elections. Frankly, the political talking points opposing the ACA’s coverage expansion have gotten old. But, more than that, they obscure the very significant changes that are occurring in the U.S. health care system—and in Michigan—as a result of the ACA.

The ACA has spawned new acronyms and programs: accountable care organizations (ACOs), Bundled Payments, Primary Care Transformation, Patient Centered Outcomes Research Institute (PCORI), Readmissions Reduction Program, Hospital Acquired Conditions Program, Value-Based Purchasing. Indeed, the ACA also includes an entire center, aptly named the Center for Medicare and Medicaid Innovation, devoted to testing new approaches to the delivery and financing of health care and improving population health.

Michigan providers, health plans and academic institutions are embracing these new approaches and changing the design of delivery systems in fundamental ways. Researchers at our large teaching institutions are actively engaged in research being funded by PCORI. Federally qualified health centers in Michigan have received new funding through the ACA  and are expanding in many parts of the state. Nineteen accountable care organizations (ACOs) are serving Michigan residents as a part of Medicare’s ACO initiatives, according to the Centers for Medicare and Medicaid Services; 62 nursing homes, hospital and other providers are participating in the Medicare bundled payment program. And 1,700 primary care providers in 277 practices statewide are participating in the Michigan Primary Care Transformation (MiPCT) project, the largest patient-centered demonstration in the country, a major initiative of the Center for Medicare and Medicaid Innovation.

While all of these initiatives have their own design features, they are all directed at the same fundamental issues: trying to improve quality, increase the integration and coordination of care across settings and improve the health care system’s cost effectiveness.

Many of these initiatives aim to get rid of the current fee-for-service system, where the more services that are provided, the more providers earn: a system whose incentives are all wrong if we want to improve the value of health care. Health policy analysts agree: more services do not necessarily result in better care and may, in fact, be harmful. Others are designed to provide more information and research about what works in health care so that practitioners can increasingly deliver care based on evidence. And, many initiatives are designed to penalize care that is inefficient and reward care and programs that improve quality and/or community health.

What all these initiatives also have in common is that we don't know if they will actually work. Indeed, while the Affordable Care Act includes just about every idea that policy analysts have come up with to improve our system of health care, most have never been tried on any significant scale. Yet, they are already having a profound effect on the health care system. All across the country and in Michigan, hospitals are consolidating and more are becoming for-profit; doctors are leaving private practice and becoming employed; health plans and government programs are negotiating with providers to press for more price concessions and share more of the risk and cost of delivering care; employers are experimenting with new programs that shift more cost to consumers (sometimes using value-based approaches and sometimes not) and consumers are becoming more engaged in health care decisions and showing their willingness to choose health plans with limited networks of doctors and hospitals in return for lower premiums or copays and deductibles.

It is certain that the debate about the ACA’s coverage provisions will rage on. But we can at least hope that those who care about health care in America actually take a step back and look at what is really happening on the ground. In the end, the ACA is a grand experiment about how to improve health and reduce costs. Let's not miss that in all the political debate that is underway.

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