In no other country does public responsibility for health costs provoke such emotional chanting of ideological warfare. While many European countries have resolved and accepted the notion of public intervention in healthcare, after many failed attempts at reform and countless public debates, the issue of US Government involvement in the healthcare sector has clearly still not been fully resolved. Not only that, but this very issue affects the very nature of the American psyche!
‘Warfare’ is the correct word to use as EVERYONE in the US seems to have an opinion on the role of the Government in health! Whether it is seen as endangering the American free-enterprise system and the doctor-patient relationship or as a social and ethical obligation to make healthcare accessible and affordable (we are not even talking about what people think about the US Affordable Care Act of 2010 yet)!
Why has the Government’s role in health care become such a contentious issue? Why is there such a lack of trust of the Government and politics/politicians in general? Due to space and content restraints, I will leave you to ponder this as I address how I think these underlying issues factor into the implications for elderly care as outlined in the 2010 Affordable Care Act (ACA) and beyond.
First, it is worth mentioning that ACA does not make an attempt to overhaul the existing US health care system. In its essence, ACA essentially maintains the private, market-based health insurance system. It keeps the existing Medicare programme intact (albeit some incremental changes), it expands Medicaid eligibility for to cover a greater number of legal residents (up to 133 percent of the federal poverty level (US$14,404 for a single adult or US$29,327 for a family of four)) and also includes provisions such as: (1) an individual mandate, (2) regulations, (3) subsidies, and (4) adjusted community premium ratings.
So what does all this mean for the elderly?
Benefits pertaining specifically to the elderly are introduced in a number of sections. Some benefits address gaps in Medicare, and others are introduced as standalone programmes. For example, the ACA includes financial incentives to reduce healthcare acquired conditions in the hospital setting and to reduce readmissions of Medicare patients to hospitals after discharge (hospital readmission programme). The ACA also introduces voluntary, self-funded, long-term care insurance through the workplace for the elderly and for people with disabilities. It allows Medicare recipients, who fall under the “donut hole,” to get a 50% discount on brand name prescription drugs and to get access to free prevention and wellness services each year. These are just some of many examples, but from these there are key takeaway points worth pondering.
Firstly, many of these programmes will not come into effect immediately. Rather implementation is set to take place over a period of years, through 2019 (the phasing out of the “donut hole” for Medicare Part D coverage, is an example).The challenge with having implementation set further into the future is that it subjects the policy to a problem known as the saliency bias (where the urgency to take action diminishes over time). Given the fact that this issue also is unresolved and evokes so many mixed emotions from such a wide variety of stakeholders, suggests that the decision to delay ACA implementation introduces higher political risk: it creates the opportunity for progress to be circumvented, changed, potentially even reversed!
Secondly, in addition to delaying implementation, congress left many specific decisions and rulemaking on ACA for the regulators to establish. In many respects, this makes sense. Compared with congress, regulators are better equipped with the technical expertise to address this issue and are in a better position to ‘theoretically’ make technical decisions devoid of politics. However, one only needs to see what is happening with Dodd Frank implementation to know that in actuality, similar to the finance sector, leaving specific decisions on ACA for regulators to establish at a later date, may not work as intentioned in practice. This can hold true for a myriad of reasons: health regulators are not completely immune to lobbyist influence, there tends to be a revolving door of regulators from the industry itself and the decision to do so can lead to the unintended effect of diminishing the sense of greater accountability to the public to ensure effective health system reform.
Thirdly, while ACA represents a potential tool for the elderly to receive more comprehensive benefits and access to care, the Act takes minimal steps to reduce the many moving parts of the system, put more bluntly, its complexity. The lack of standardized rules regulating payment, coverage and provision, translates to an operational challenge to beneficiaries, especially the elderly. It will require them to single-handedly navigate and coordinate their services as they move from one benefit programme to another. Understanding ACA remains daunting to me, and I am a mid-career policy analyst, so you can imagine, how much more challenging and confusing it must be for the elderly to fully comprehend and experience! The sheer complexity, fragmentation, distrust and differing opinions on ACA, open the benefits provided to misunderstanding, misrepresentation and unintended consequences. On the latter, ACA may lead to the disruption of care services as eligibility requirements for different programmes may differ. Reimbursement differences may affect incentives for the provision and utilisation of services. To elaborate on this point, George Washington University’s School of Nursing Assistant Research Professor Ellen Kurtzman, lists some examples of unintended negative consequences in provision of care for the elderly under the ACA in an article (I have chosen to just list two of them):
• The National Pilot Programme on Payment Bundling reimburses a fixed amount to a hospital system for an episode of care and is aimed at delivering high quality outcomes at lowest possible cost, while avoiding post-acute stays and preventable rehospitalisations. However, the programme does not include bundle payments for long-term services and support so there are no incentives to coordinate care before or beyond the bundle.
• The Community-Based Care Transitions Programme, allow hospitals to serve as the “hubs” of care. However, it may prevent frail older adults who are not hospitalised or who live outside the geographic regions served by these organisations to have adequate access to transitional care services.
Thus, despite its benefits, ACA does seem to further complicate healthcare financing and delivery in the US health system. The sheer complexity of different programmes and initiatives fragments the system, causes greater room for misconceptions and misinterpretations and introduces some unintended consequences, all to the detriment of serving the population at-large.
The US has gotten itself in a bit of a muddle: while many Americans believe healthcare reform towards universal health coverage is needed to allow healthcare to be available at a price that is affordable, due to the unresolved issues surrounding the appropriate role of Government in health, everyone has a differing opinion on how to get there.
By the current nature of ACA’s design, it is clear that policy-makers made some sacrifices. In the need to design a policy that will pass congress (i.e. to maintain status quo, not offend too many stakeholders), ACA ended up not really doing much to fundamentally address the much needed health system overhaul that underlying dynamics in US population structures, costs and epidemiological conditions, require.
What will it take to bring about the needed change in health reform in America? Will the land of opportunities continue to allow itself to be mired in this ideological policy trap, amidst a clear need for reform?
Email from Joe Albers Summarizing a Policy Analysis Brief of Affordable Care Act of 2010 dated July 17, 2012.
Medicalxpress. 2012. “The Affordable Care Act Could Have Negative Consequences for Elderly Recipients” By Ellen Kurtzman, June 22, 2012 http://medicalxpress.com/news/2012-06-negative-consequences-elderly-recipients.html#jCp Accessed July 25 2012
Starr, Paul. 2011. Remedy and Reaction: The Peculiar American Struggle over Health Care Reform (Yale University Press, October).