Spring 2014

Inside Obamacare

One of the architects of the Affordable Care Act talks about its lesser-known benefits

By Jacqueline Mitchell

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“The challenge going forward is to be sure that care is integrated, effective, cost-effective and humane and that we as a nation can afford it,” says Harry Selker. Photo: Alonso Nichols

Since it became law in 2010, the Patient Protection and Affordable Care Act (ACA) has been one of the most hotly debated pieces of legislation in recent years. It continues to be controversial as it is implemented. For more than 15 years, Harry P. Selker, dean of the Tufts University Clinical and Translational Science Institute (CTSI) and professor of medicine, worked closely on the issue with policymakers, including with the offices of the late Sen. Edward M. Kennedy (D-Mass.), Sen. Max Baucus (D-Mont.) and Rep. Henry Waxman (D-Calif.).

Selker is a national leader in translational science, which aims to bring high-impact, cost-effective health care out of the lab and to the patient—the so-called “bench to bedside.” But translational science shouldn’t stop there, says Selker. Good research, he says, makes for good public policy.

Selker and June Wasser, instructor of medicine and former Tufts CTSI executive director, are the editors of a new book, The Affordable Care Act As a National Experiment: Health Policy Innovations and Lessons (Springer), in which leading health-policy experts examine the history, objectives and impact of the law that has become known as Obamacare.

Selker took a moment recently to talk with us about how the law will improve America’s health-care system.

Tufts Medicine: What changes will consumers feel immediately?

Harry Selker: The first thing we’re going to notice is that millions more Americans will be able to get health-care insurance—ultimately 23 million. We as a nation, I think, have an obligation to provide health care as a basic need of life for our citizens. It’s a profoundly important responsibility in support of health, welfare and fulfillment of potential.

As part of this expansion of coverage, there are other key changes that most people already know about. People with pre-existing medical conditions now will be able to get coverage, and insurance can’t be dropped as soon as a person gets sick, so that long nightmare is over. And for those covered by Medicare, Part D prescription drug coverage is enhanced so the “doughnut hole” in payment coverage now is filled. This means that more people will be able to afford their medication because less will be required out of pocket.

What are some of the lesser-known elements of the new law?

Other parts of the law pertain to payment for medical care. The ACA has increased reimbursement for primary-care physicians, which is crucial. Right now there aren’t enough primary-care physicians, in part because they aren’t paid adequately. The financial incentives are greatly skewed toward the performance of procedures and the specialists who perform them. Thus, young physicians with large debt loads from medical school feel they cannot afford to go into primary care. The ACA attempts to change this.

There are also important components of the ACA that crack down on insurance fraud and abuse, increase transparency in the flow of insurance funds and require that at least 80 percent of insurance dollars be used for patient care.

Ultimately, by these and other measures, the ACA will change the way medicine is practiced. It will help change from care that is based on fee-for-service to a model of coordinated payment that should support care based on what is best for the patient and most efficient—a needed change that has been recognized for decades.

Another expansion of coverage is that the ACA has provisions that will allow people who are disabled to get help at home so they can stay there. It’s much more humane.

Does the ACA do research on the improvement of health-care delivery?

Embedded in the ACA is the creation of two research centers: the Patient-Centered Outcomes Research Institute and the Innovation Center at the Center for Medicare and Medicaid Services (CMS).

The newly created CMS Innovation Center was allocated $10 billion to spend over 10 years on projects to find ways to make health-care delivery more attractive, effective and efficient. For example, if Medicare paid for more home health-care services and attention to home conditions, might it avert illness or injuries that would lead to hospitalizations?

A novel and crucial aspect of the role of the CMS Innovation Center is that as its research provides ways to deliver care better, these findings can be directly implemented to improve national health-care policy. The law allows the Secretary of Health and Human Services to implement the new policies immediately, rather than waiting for congressional action—or inaction—as has been the case for Medicare policy changes in the past.

What will the patient-centered outcomes institute do?

Those of us involved in writing the legislation creating the Patient-Centered Outcomes Research Institute (PCORI) saw it as a way to support research that will inform patients, doctors and the public about the comparative effectiveness of various treatments. It was framed to provide information that will help people make good decisions.

The trade-offs made in creating PCORI illustrate some of the “sausage making” that characterizes writing legislation. In assessing the financial impact of the ACA—which was a critical aspect of the overall legislation, as there were limits to how much it would be allowed to cost—the nonpartisan Congressional Budget Office identified PCORI as one of the parts of the ACA that would save money. By conducting comparisons between treatments, then the least expensive one could be chosen.

The challenge going forward is to be sure that care is integrated, effective, cost-effective and humane and that we as a nation can afford it. There will be more changes down the road. If what we did here in Massachusetts was health-care reform 1.0, the ACA is health-care reform 2.0. We still have a lot more to do.

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