The Affordable Care Act 10 Years In: What Nursing Leaders Should Know

Abstract

The Affordable Care Act (ACA) introduced wide-ranging health care reforms but faces many challenges. This article reviews 6 key points for today’s nurse leader on the law’s 10th anniversary: a renewed legal battle is on its way to the Supreme Court; 27 million people still lack coverage, partly due to nonexpansion of Medicaid in 15 states; Medicaid waivers provide coverage for some low-income people but leave many people out; value-based purchasing has allocated billions of dollars in rewards and penalties; ACA Marketplace plans are not always affordable, but premiums are stabilizing; and the 2020 elections could result in dramatic consequences for health care reform. The Affordable Care Act (ACA) introduced wide-ranging health care reforms but faces many challenges. This article reviews 6 key points for today’s nurse leader on the law’s 10th anniversary: a renewed legal battle is on its way to the Supreme Court; 27 million people still lack coverage, partly due to nonexpansion of Medicaid in 15 states; Medicaid waivers provide coverage for some low-income people but leave many people out; value-based purchasing has allocated billions of dollars in rewards and penalties; ACA Marketplace plans are not always affordable, but premiums are stabilizing; and the 2020 elections could result in dramatic consequences for health care reform. Key points•The Affordable Care Act nearly halved the uninsured rate and incentivized a focus on health care quality and outcomes.•Ongoing legal wrangling, inconsistent state decisions, and selective enforcement of the Act have attenuated its impacts.•Current challenges include consistency of coverage for low-income Americans, affordability and comprehensiveness of Marketplace plans, and effectiveness of value-based purchasing programs. •The Affordable Care Act nearly halved the uninsured rate and incentivized a focus on health care quality and outcomes.•Ongoing legal wrangling, inconsistent state decisions, and selective enforcement of the Act have attenuated its impacts.•Current challenges include consistency of coverage for low-income Americans, affordability and comprehensiveness of Marketplace plans, and effectiveness of value-based purchasing programs. In 2010, the passing of the Patient Protection and Affordable Care Act (ACA) was the first successful attempt at health care reform in decades. Despite criticism, it nearly halved the uninsured rate in the United States through a largely market-based approach to reform. The goals of the ACA were to increase access to care, improve quality, contain costs, and encourage innovation. Today, the ACA faces many challenges, including ongoing attempts to dismantle or remove it. On its tenth anniversary then, it is time to review this massive legislation and highlight several key points for today’s nursing leader. Having survived numerous attempts in Congress to repeal it, the ACA is facing a new lawsuit that could yet spell its demise. The suit, Texas v. United States, claims that the “individual mandate”—the requirement that most people show proof of health insurance coverage—is unconstitutional, because Congress cannot force citizens to purchase anything.1Texas v. United States, 945 F.3d 355(5th Cir. 2019).Google Scholar The Supreme Court already ruled in 2012 that, although the individual mandate was not a lawful use of Congress’ power to regulate commerce, it was a lawful use of Congress’ power to raise taxes.2National Federation of Independent Business v. Sebelius, 567 U.S. 519(U.S. 2012).Google Scholar Since the penalty for failing to show health insurance coverage was just an additional fee on a person’s income tax return, the Court saw the mandate as a tax and therefore constitutional. What’s changed since that 2012 case? The Tax Cuts and Jobs Act (TCJA), passed by the Republican-led Congress in 2017, reduced the penalty for failing to comply with the individual mandate to $0.3Tax Cuts and Jobs Act, Pub. L. No. 115-97, 131 Stat. 2054 (2017).Google Scholar If no tax revenue is collected, the plaintiffs in Texas v. United States argue, then the mandate is not really a tax, but rather an unlawful attempt by Congress to compel people to buy something. But should the whole ACA be nullified? The federal judge in Texas who heard the case in 2018 ruled that the mandate cannot be severed from the rest of the law: if the mandate must go, so must the whole ACA. In December, an appeals court agreed that the mandate is now unconstitutional but punted the decision on severability.1Texas v. United States, 945 F.3d 355(5th Cir. 2019).Google Scholar When the Supreme Court takes up the case later this year, all eyes will be on Chief Justice Roberts, who is seen as the swing vote, having sided with the Court’s 4 “liberal” justices in 2012.4Fuse-Brown E, Segall E. Update on litigation to strike down the Affordable Care Act. Paper presented at: Georgia State University Center for Law, Health & Society; September 10, 2019; Atlanta, GA.Google Scholar Whatever happens, it’s important for nursing leaders to remember that the ACA is many things, not just the mandate. The other 2 legs of the ACA’s “3-legged stool” are the tax credits to help individuals purchase health plans on the ACA Marketplaces, and the ban on denying coverage or charging more to people with pre-existing medical conditions.5Patient Protection and Affordable Care Act, 42 U.S.C., §18001 et seq. (2010).Google Scholar And those provisions are just Title I of the Act; there are 8 other Titles that include wide-ranging reforms, from Medicaid eligibility to Medicare reimbursement to funding for patient-reported outcomes research. Therefore, how our patients access care—and how that care is paid for—would be affected by the ACA’s abrupt undoing. About 27 million people (8.5%) in the United States still lack health insurance despite the gains in coverage under the ACA.6Berchick E.R. Barnett J.C. Upton R.D. Health Insurance Coverage in the United States: 2018. U.S. Census Bureau, November 2019https://www.census.gov/content/dam/Census/library/publications/2019/demo/p60-267.pdfDate accessed: April 28, 2020Google Scholar Some people without access to insurance through an employer or government program do not purchase coverage on their own, even if they qualify for tax credits under the ACA to help them do so, and even though (prior to the TCJA) it meant paying a penalty. They may be unaware of or exempt from the requirement or simply refuse to purchase coverage. Some are temporarily locked out of Medicaid programs in states with certain beneficiary obligations (see next section). But a large share of uninsured people—nearly 5 million—fall into the “coverage gap” that persists in the 15 states not currently participating in Medicaid expansion under the ACA.7Garfield R. Orgera K. Damico A. The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid. Kaiser Family Foundation, January 2020https://www.kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/Date accessed: April 28, 2020Google Scholar Medicaid is a joint federal–state program that has provided health coverage to some (but not all) low-income people since the 1960s. With some minimum national standards, states have freedom to decide their own eligibility criteria. Title II of the ACA was meant to standardize and expand Medicaid eligibility: everyone earning below 138% of the federal poverty level would qualify for coverage.5Patient Protection and Affordable Care Act, 42 U.S.C., §18001 et seq. (2010).Google Scholar The federal government would pay most of the costs for the newly eligible population (100% at first, tapering to 90% in 2020), and states that did not agree to participate would lose their federal Medicaid dollars. But the Supreme Court surprised many observers by ruling that the federal government could not withhold all Medicaid funds if states declined to participate in Medicaid expansion.2National Federation of Independent Business v. Sebelius, 567 U.S. 519(U.S. 2012).Google Scholar The result has been a staggered, patchwork expansion of Medicaid, leading to the persistence of sizable coverage gaps in nonexpansion states. (Ironically, many low-income, uninsured people in nonexpansion states do not qualify for tax credits to purchase insurance on the Marketplaces, because those credits are reserved for incomes at 100% to 400% of the poverty level.) Today, nonexpansion states are clustered in the Southeast (Figure 1), where many health indicators—from stroke incidence to maternal death—already lag behind the rest of the country. In a systematic review of 62 studies, Medicaid expansion was associated with increased access to care—for example, preventive health visits and chronic disease management—and quality of care—for example, glycemic monitoring for diabetes and blood pressure control.8Mazurenko O. Balio C.P. Agarwal R. Carroll A.E. Menachemi N. The effects of Medicaid Expansion under the ACA: a systematic review.Health Aff (Millwood). 2018; 37: 944-950Crossref PubMed Scopus (99) Google Scholar Individual studies have shown that expansion also correlates with declines in non-emergent use of the emergency department9Sommers B.D. Blendon R.J. Orav E.J. Both the 'private option' and traditional Medicaid expansions improved access to care for low-income adults.Health Aff (Millwood). 2016; 35: 96-105Crossref PubMed Scopus (73) Google Scholar and lengths of hospital stays.10Holzmacher J.L. Townsend K. Seavey C. et al.Association of expanded Medicaid coverage with hospital length of stay after injury.JAMA Surg. 2017; 152: 960-966Crossref PubMed Scopus (13) Google Scholar,11Pickens G. Karaca Z. Cutler E. et al.Changes in hospital inpatient utilization following health care reform.Health Serv Res. 2018; 53: 2446-2469Crossref PubMed Scopus (16) Google Scholar Yet Medicaid expansion is no panacea. Many providers are reluctant to accept new Medicaid patients due to low reimbursement rates, which can limit de facto access to care. Some states have protested that a contribution of 10% for the expansion population still amounts to millions of dollars a year in spending, raising questions about long-term solvency and the availability of revenue for other services. A study in Montana, however, found that cost-savings in other state-funded programs and increased economic activity (including new jobs and tax revenue) largely offset the cost of expansion.12Bureau of Business and Economic ResearchThe Economic Impact of Medicaid Expansion in Montana.https://mthcf.org/wp-content/uploads/2018/04/BBER-MT-Medicaid-Expansion-Report_4.11.18.pdfDate: 2018Date accessed: April 28, 2020Google Scholar Similar projections have been made for Nebraska and Kansas, though expansion has yet to be implemented in those states. Several states have sought and received “demonstration waivers” to expand coverage for low-income adults by alternative means under Section 1115 of the Social Security Act. These Section 1115 waivers are politically viable routes to Medicaid expansion in some states and can take various forms. For example, Arkansas’ “private option” uses expansion dollars to buy private health plans for eligible people rather than expanding the state Medicaid program.9Sommers B.D. Blendon R.J. Orav E.J. Both the 'private option' and traditional Medicaid expansions improved access to care for low-income adults.Health Aff (Millwood). 2016; 35: 96-105Crossref PubMed Scopus (73) Google Scholar, 13Musumeci M.B. Hinton E. Rudowitz R. Section 1115 Medicaid Expansion Waivers: A Look at Key Themes and State Specific Waiver Provisions. Kaiser Family Foundation, August 2017https://www.kff.org/report-section/section-1115-medicaid-expansion-waivers-a-look-at-key-themes-issue-brief/Date accessed: April 28, 2020Google Scholar States may receive waivers to use the money for employer-based health plans that some low-income workers are eligible for but cannot afford.13Musumeci M.B. Hinton E. Rudowitz R. Section 1115 Medicaid Expansion Waivers: A Look at Key Themes and State Specific Waiver Provisions. Kaiser Family Foundation, August 2017https://www.kff.org/report-section/section-1115-medicaid-expansion-waivers-a-look-at-key-themes-issue-brief/Date accessed: April 28, 2020Google Scholar And a few states have used waivers to introduce new obligations for beneficiaries, such as mandatory financial contributions, copays above normal limits, and lockout periods for failure to pay.13Musumeci M.B. Hinton E. Rudowitz R. Section 1115 Medicaid Expansion Waivers: A Look at Key Themes and State Specific Waiver Provisions. Kaiser Family Foundation, August 2017https://www.kff.org/report-section/section-1115-medicaid-expansion-waivers-a-look-at-key-themes-issue-brief/Date accessed: April 28, 2020Google Scholar The more headline-grabbing waivers in recent years have to do with a novel provision for expanded Medicaid: work (or community engagement) as a condition for eligibility. Arkansas was permitted to roll out a work requirement in 2017, but a federal court suspended it—and rejected a proposal for a similar program in Kentucky—in March 2019. In the Kentucky case, the work requirement and other beneficiary obligations (e.g., monthly payments) were projected to cause nearly 100,000 people to lose coverage.14Stewart v. Azar, 366 F.Supp.3d 125(D.D.C. 2019).Google Scholar Although Trump administration officials twice approved this waiver, the court annulled it both times for its failure to promote Medicaid’s central objective of “furnish[ing] medical assistance” to the needy.14Stewart v. Azar, 366 F.Supp.3d 125(D.D.C. 2019).Google Scholar The evidence on the comparability of 1115 waivers to conventional Medicaid expansion is mixed. A study of the Arkansas private option before the work requirement found that declines in the uninsured rate and skipping medications due to cost were similar to those attained with conventional expansion (though trouble paying medical bills did not decline as much).9Sommers B.D. Blendon R.J. Orav E.J. Both the 'private option' and traditional Medicaid expansions improved access to care for low-income adults.Health Aff (Millwood). 2016; 35: 96-105Crossref PubMed Scopus (73) Google Scholar After 7 months of the work requirement, however, Arkansas dropped more than 18,000 people from Medicaid—a number of whom were unaware of the requirement or encountered administrative or technological barriers to complying with the mandatory reporting.15Musumeci M.B. Rudowitz R. Lyons B. Medicaid Work Requirements in Arkansas: Experience and Perspectives of Enrollees. Kaiser Family Foundation, December 2018https://www.kff.org/medicaid/issue-brief/medicaid-work-requirements-in-arkansas-experience-and-perspectives-of-enrollees/Date accessed: April 28, 2020Google Scholar In Indiana, over 286,000 low-income people saw their health benefits curtailed when they could not make mandatory monthly contributions.16The Lewin GroupHealthy Indiana Plan 2.0: POWER Account Contribution Assessment.https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-POWER-acct-cont-assesmnt-03312017.pdfDate: March 2017Date accessed: April 28, 2020Google Scholar If more negative outcomes emerge, opponents may again challenge waivers in court—or a future administration could reject them. The ACA accentuated Medicare’s long-term shift in focus from cost containment to quality and value. For example, the ACA supported the expansion of accountable care organizations (ACOs), which are networks of providers who accept responsibility—financial and clinical—for a group of patients. The basic model, Medicare Shared-Savings Programs, pays participating ACOs the full fee-for-service rate plus a share of any savings achieved through better care coordination.17Stroumsa D. Tabak R. Lausch K. Shigekawa E. An In-Depth Look at the Six Cost Containment Programs in the Affordable Care Act. Center for Health & Research Transformation, May 2014https://chrt.org/publication/depth-look-six-cost-containment-program-affordable-care-act/Date accessed: April 28, 2020Google Scholar To share in savings, ACOs are now expected to perform on 23 quality measures (down from 33), such as preventive health screenings, blood pressure control, and a new care coordination item on the patient survey.18Centers for Medicare & Medicaid ServicesMedicare Shared Savings Program: Quality Measurement Methodology and Resources.https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/quality-measurement-methodology-and-resources.pdfDate: May 2019Date accessed: April 28, 2020Google Scholar By 2018, there were 10.5 million beneficiaries in 561 ACOs, which earned a total $983 million in shared savings.19Centers for Medicare & Medicaid ServicesShared-Savings Program Fast Facts.https://www.cms.gov/files/document/2020-shared-savings-program-fast-facts.pdfDate: January 2020Date accessed: March 17, 2020Google Scholar The ACA also required the Centers for Medicare & Medicaid Services (CMS) to introduce the Hospital Value-Based Purchasing (VBP) program. The current VBP program withholds 2% of all Medicare inpatient reimbursement (up from 1% initially) and uses it to reward hospitals for their performance on a set of quality measures.17Stroumsa D. Tabak R. Lausch K. Shigekawa E. An In-Depth Look at the Six Cost Containment Programs in the Affordable Care Act. Center for Health & Research Transformation, May 2014https://chrt.org/publication/depth-look-six-cost-containment-program-affordable-care-act/Date accessed: April 28, 2020Google Scholar Previous measures focused on care processes (e.g., fibrinolytic therapy for myocardial infarction [MI] within 30 minutes), patient satisfaction, and condition-specific mortality. In recent years, however, the process measures were replaced by rates of hospital-acquired conditions (HACs), Medicare spending-per-beneficiary, and additional mortality rates.20Centers for Medicare & Medicaid ServicesHospital Value Based Purchasing (HVBP) Program FY 2018-2025 Measures.https://www.qualitynet.org/inpatient/hvbp/measuresDate accessed: March 17, 2020Google Scholar Failure to perform on these measures affects a hospital’s bottom line. In addition, CMS created a consumer-facing website that publishes results on each measure, allowing comparison of hospitals by performance. Meanwhile, the ACA required state Medicaid programs to stop paying for HACs, such as pressure ulcers, fall-related fractures, and postoperative sepsis, in 2011; beginning in 2015, it reduced Medicare payments by 1% to hospitals that rank in the worst-performing 25% for HAC measures.17Stroumsa D. Tabak R. Lausch K. Shigekawa E. An In-Depth Look at the Six Cost Containment Programs in the Affordable Care Act. Center for Health & Research Transformation, May 2014https://chrt.org/publication/depth-look-six-cost-containment-program-affordable-care-act/Date accessed: April 28, 2020Google Scholar Moreover, the ACA required CMS to reduce payments to hospitals with excess readmissions starting in 2012. At first, CMS defined readmission as any hospitalization within 30 days of discharge for MI, heart failure, or pneumonia, and later expanded the list to include chronic obstructive pulmonary disease, total hip/knee arthroplasty, and coronary artery bypass surgery. Readmission penalties totaled $528 million in 2017, less than 1% of hospitals’ Medicare inpatient revenue.21Boccuti C. Casillas G. Aiming for Fewer Hospital U-Turns: the Medicare Hospital Readmission Reduction Program. Kaiser Family Foundation, 2017https://www.kff.org/medicare/issue-brief/aiming-for-fewer-hospital-u-turns-the-medicare-hospital-readmission-reduction-program/Date accessed: April 28, 2020Google Scholar The initial value-based efforts focused on inpatient facilities, where cost was the highest, but today there are other VBP programs for skilled nursing facilities and home health, among others. However, the deployment of VBP by government payers to reward providers for quality and outcomes has not been widely replicated in the private sector. By contrast, many private health insurance plans, including those sold on the ACA Marketplaces, have focused on patient-side cost-containment tools such as deductibles, pre-authorization, and coinsurance. Average monthly premiums for Marketplace plans are stabilizing—and actually decreased slightly in 202022Fehr R. Kamal R. Cox C. How ACA Marketplace Premiums Are Changing by County in 2020. Kaiser Family Foundation, November 2019https://www.kff.org/health-costs/issue-brief/how-aca-marketplace-premiums-are-changing-by-county-in-2020/Date accessed: April 28, 2020Google Scholar—after a period of uncertainty from the zeroing out of the individual mandate penalty, which removed an incentive for healthy people to buy insurance, and from the Trump administration’s withholding of cost-sharing reduction (CSR) payments to offset the “extra savings” that Silver-level plans must provide to lower-income members. Similarly, the administration’s promotion of cheaper, bare-bones plans that do not cover all the essential health benefits defined in the ACA has raised concern that only sicker or riskier people will buy comprehensive health plans (driving up prices), but others suggest that bare-bones plans tend to attract people who wouldn’t be purchasing a Marketplace plan anyway. Why are premiums stabilizing? Insurers have mitigated the impact of the loss of CSR payments by raising premiums for just Silver-level plans, since the size of tax credits that people receive to buy insurance on the Marketplaces is pegged to the cost of those plans.22Fehr R. Kamal R. Cox C. How ACA Marketplace Premiums Are Changing by County in 2020. Kaiser Family Foundation, November 2019https://www.kff.org/health-costs/issue-brief/how-aca-marketplace-premiums-are-changing-by-county-in-2020/Date accessed: April 28, 2020Google Scholar As a result, more generous Gold plans are sometimes as cheap to patients as Silver plans, whereas Bronze plans may be free altogether (though they come with higher out-of-pocket costs at the point of care). In addition, reinsurance programs may be helping to rein in premiums in several states. Also called high-risk pools, these programs use public funds to pay the most expensive medical claims so health insurers do not need to account for them when they set their monthly premiums. State-run reinsurance may reduce individual-market premiums by an average 17%.23Sloan C. Rosacker N. State-Run Reinsurance Programs Reduce ACA Premiums by 16.9% on Average. Avalere, October 2019https://avalere.com/press-releases/state-run-reinsurance-programs-reduce-aca-premiums-by-16-9-on-averageDate accessed: April 28, 2020Google Scholar Finally, states with Medicaid expansion have lower average Marketplace premiums, partly due to “spillover effects”: expanded Medicaid may draw some people with lower incomes and poorer health out of the individual insurance market, lowering the cost of Marketplace plans.24Weiss M, McCarthy IM. Medicaid expansion and Marketplace premiums: evidence from late-adopting states. Poster presented at: Emory Summer Undergraduate Research Symposium 2019; Atlanta, GA.Google Scholar It is possible that the fluctuation in Marketplace premiums over the past several years was a straightforward (if messy) free-market process: insurers were guessing what their losses from Marketplace plans would be, set their initial premiums accordingly, then adjusted them until their losses were sustainable. If this view is correct, there is reason to hope that the pause in premium rises will hold for now. Nonetheless, the problem of high out-of-pocket costs—especially deductibles—will need to be addressed if affordability and access are to be achieved. Competing ideas about how to attain truly universal health coverage consumed much airtime at Democratic Party presidential debates this election cycle. There are roughly two schools of thought among Democrats: build on what’s working from the ACA or replace it with a version of “Medicare for all.” The build-on-what’s-working camp generally favors the addition of a public option for health insurance—essentially an expansion of Medicare “for all who want it.”25Simon S. Glenn H. “Just the right policy”: Pete Buttigieg on his “Medicare For All Who Want It” plan.Morning Edition. National Public Radio, November 8, 2019Google Scholar However, unlike the Medicare-for-all enthusiasts, they would not abolish private health insurance and replace it with a single-payer scheme akin to Canada’s. The reality is that even incremental reforms would face headwinds in Congress, whichever party is in charge, but the campaign rhetoric suggests that a Democratic president would move the goal posts closer to universal coverage—and a bigger role for federal government—in 2021. If Republicans hold onto the White House and win big in Congress, they may finally have the votes to repeal the ACA (with or without a replacement). Alternatively, the administration could perpetuate the incremental, back-channel approach to hollowing out the ACA, including through litigation and judicial appointments. If any outcome again destabilizes insurance markets or undermines expanded programs, however, expect resistance to come from all sides. After all, Medicare began as a controversial policy in the 1960s and now enjoys broad support across the American public; taking away benefits is rarely more popular than opposing them in the first place. Blake T. McGee, PhD, MPH, RN, is Assistant Professor at the Byrdine F. Lewis College of Nursing and Health Professions, Georgia State University, Atlanta, Georgia. He can be reached at [email protected] . Susan E. Breslin, DNP, RN, FACHE, is Clinical Assistant Professor at the Byrdine F. Lewis College of Nursing and Health Professions.