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The media seem to be finally united on one point about the Affordable Care Act: it is not going to be repealed.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While pundits seem to agree that the law is not going to be repealed, the ACA continues to figure heavily in many midterm elections.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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Thu, 06/12/2014 - 8:27pm
"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." I wonder why the proponents of ACA, Obamacare, only see that others should take the step back and look at reality. I wonder why those who are so enamored with the law cannot accept that people are concerned by the ethics or lack of ethics used in getting it passed and are concerned that those same people will not use the same means and methods to justify its existence and resistance to change. I wonder why those who claim the changes from Obamacare are so quick to ignore the efforts and successes of those who were working on those changes long before the law came along. I wonder why those want us to move on and support the Affordable Care Act cannot see the consequences that people were not warned of and are suffering. I wonder why people are so sure of the law that they can only mention the numbers they feel justify the law and ignore those numbers that identify the problems with the law. I have yet to see a law or program that was ‘the answer’ when it discouraged an open discussion that included/encouraged participation by people with differing views.
Fri, 06/13/2014 - 5:26pm
Another question, why are things so settled that debate should end and the opposition should just roll over on things like Obamacare and other leftwing programs, but take campaign finance(Citizens United), Right to Work, and gun control ... and debate and the battle never ends?
Fri, 06/13/2014 - 11:13pm
Matt, I am afraid your concern is lost on those who care more about the poltiics of power and control than on achieving the desired results. The power and control crowd want the name plate legislation that they can dragout and wave as a flag or their power each time the find a new issue the want to take credit for. Where the people who really care about change and achieving desired and long lasting results see each issue as and 'elephant' to be eat one small bite at a time. Obamacare is a good example, it is to be a legacy banner so rather then to work on each piece such as building on the already working insurance exchanges they want to create the government's own so they could claim it as part of the legacy use to judge the President. Similarly they wanted control so they created a means for IRS involvement, which always means control, rather then simply creating a voucher system. It is driven by those who need power for self justification rather then wanting people to chose what they want and will do to achieve it. Your question on campaign financing is an example rather they asking why campaign money is so important they simply want to control it. Even on the pages of Bridge this is happening. I would offer, if people would truly want resolve issue in a way that provided for a sustainable result they would start by asking questions rather then stating their answers.
Dedra Dee
Tue, 06/17/2014 - 11:24am
How many years do you want the debate to go on? Six years is not long enough?
Wed, 06/18/2014 - 9:59pm
Debra, The debate will last as long as it is convenient for those who control the process. The reality is that if the politicians care about the results rather then their legacy then they would incorporate the means and methods to measure the effectiveness of programs/laws and require the administrating agencies to modify programs and activities to improve performance. Otherwise we get what we have with the IRS and VA. Is it better to get a bad action or no action?
Dedra Dee
Tue, 06/17/2014 - 11:21am
Why are you so stuck on the past? Why can't you see the future? Who are the people that were working on this for so long that we have forgotten? Wonder why they never came up with a program that I have heard of? Why after all these years haven't the republicans come up with a replacement plan that is better than Obamacare? Just wondering.
Wed, 06/18/2014 - 10:03pm
Debra, Do you believe that Obamacare or any of the other government programs are the best they can be? If not, then why do you only expect the Republicans to come up with alternatives? Is it better to simply keep patching a problem, like the registration process for Obamacare (which seems to still not be done, or are there time to simply scrap and replace or even start with a blank page?
Mon, 07/07/2014 - 1:42pm
Great parts of the web site, .gov have not even been build. HHS is asking for $120M MORE to fix it for this fall. Mass. had a working web site, tried to make it work for OweBamaCare and could not after spend $50M of a $97M grant and now has given it to HHS to TRY to run. Same with Oregon after getting $248M and spending at least $160M NEVER signed up one single person on the web site, not one. Hawaii is in trouble, MN too. Maryland want $50M more to make theirs work and then deciding to go with the Conn. one. All in all $4.6B were given to the states to make web sites and exchanges. Why re-invent the wheel?