The loud debate over how many people have gotten health insurance under the Affordable Care Act misses the point. Yes, reducing the number of uninsured was one goal of the ACA. But only one. The law’s most enduring legacy will come from its historical—but largely unnoticed—changes in the way health care is delivered.
Unlike the insurance expansion, which largely excludes Medicare, many of those delivery reforms affect seniors and younger people with disabilities. In some cases, they are remaking the care people get through Medicare. In others, they change the way care is delivered through Medicaid, which is critical for many receiving long-term services and supports.
Most of these delivery reforms targeted what Don Berwick (who ran the Medicare and Medicaid programs during the debate over the ACA) dubbed the Triple Aim: Improving the quality of care and the health of populations, and reducing per capita costs. And while they only directly affect Medicare and Medicaid beneficiaries, private insurers are already picking up many of the same ideas.
The ACA includes dozens of programs aimed at accomplishing those goals. And, wisely, rather than imposing top-down solutions, it provides financial and regulatory incentives that encourage private market and state experiments.
It is accelerating a ground-breaking shift away from fee-for-service medicine to managed care. And it is redesigning payment systems so medical and long-term care providers will share financial risk for high-cost, low-quality care and financial rewards for high-quality, low-cost care.
Here are just a few examples:
- More than two dozen states are developing managed care programs that will integrate medical treatment and long-term supports and services for low-income people with chronic disease and injury. While still largely unproven, these have the potential to provide better quality, well-integrated care at less cost.
- New federal money is encouraging states to expand their Medicaid home and community-based care programs and keep the frail elderly and younger people with disabilities out of nursing homes.
- Primary care physicians are being paid extra to run patient-centered medical homes where one doctor can quarterback care from multiple specialists—another important change for seniors who may have many chronic conditions.
- It vastly expended the development of Accountable Care Organizations and created bundled payment arrangements. In these models, a broad range of providers—hospitals, doctors, nursing homes, home care agencies, and others—work together to deliver the full range of care following an acute medical episode. For instance, if mom falls and breaks her hip, an ACO would be paid a fixed amount of money for her hospitalization, hip surgery, rehab, and home care. Such a design would encourage all participating providers to work as a team to ensure the best possible outcome.
- Medicare is cutting payments to hospitals that have excessive readmissions. While these penalties were not technically part of the ACA, they fit the spirit of the law. And more than any other regulatory reform I’ve seen, they have changed the way hospital administrators think about their patients. No longer are you on your own after you are rolled out the front door. Now, hospitals are running transitional care programs to make help discharged patients manage their medications and do physical therapy, and are extra careful to avoid infections.
Despite all the partisan yelling and screaming about “Obamacare,” most of these changes have broad bipartisan political support. And they all have the potential to greatly improve the way many of us—especially seniors—get care.
As usual, the politicians and most of the media are obsessing over one piece of a huge new law. But long after last year’s bungled rollout of the health insurance exchanges is a distant memory, these delivery changes will be affecting all of our lives. They will be the real legacy of the Affordable Care Act.