Technical defects have plagued early implementation of the Affordable Care Act’s health insurance marketplaces, a central component to the law’s long-term success or failure. President Obama on Monday shared his own frustration with what he called glitches in the system. “Nobody’s madder than me about the website not working as well as it should, which means it’s going to get fixed,” Obama said from the Rose Garden.
The Republican Party has taken every opportunity to cheer on the failures of the system. This is what happens when you allow the government to try to help, they say. But while the administration’s failures in setting up a workable exchange is, as the Los Angeles Times recently noted, something that “could inflict a greater toll on the Affordable Care Act than the law’s opponents have,” it is important to remember why passing health care reform was so necessary and urgent in the first place. The United States healthcare system is completely broken, for two primary reasons.
First, the United States stands alone among industrialized nations in not providing health coverage to all of its citizens. In 2009, 46 million Americans lacked health coverage, the consequences of which are severe. Relative to the uninsured, insured Americans are more likely to obtain recommended screening and care for chronic conditions and are less likely to suffer undiagnosed chronic conditions or to receive substandard medical care. Indeed, according to one study, lack of health insurance is associated with as many as 44,789 deaths per year in the U.S., more than those caused by kidney disease (n=42,868).
The Affordable Care Act marks a crucial turning point. The Act makes high-quality healthcare accessible to millions of Americans, including those Americans who have been priced out of the market. Taken together, the provisions in the law are estimated to expand coverage to 32 million Americans. Unfortunately, however, about 5.2 million poor, uninsured adults will fall into the “coverage gap” created by 27 states choosing not to expand Medicaid.
Second, U.S. healthcare spending dwarfs that of other countries. According to a May 2012 Commonwealth Fund study, the U.S. spent nearly $8,000 per person for health care services in 2009. Norway and Switzerland were a distant second and third behind, respectively, on medical spending, at a little more than $5,000 per person.
The high rate of spending in the U.S., however, doesn’t necessarily make for a high standard of care. Rather, according to the study, quality indicators show variable performance in the U.S. For example, although the U.S. had the highest survival rates for breast cancer (89%) and colorectal cancer (65%), the survival rate for cervical cancer (64%) was worse than the OECD median and the U.S. had the highest rates of mortality due to asthma and lower-extremity amputations due to diabetes per 100,000 population.
The Affordable Care Act is the most far-reaching effort to contain healthcare costs to date. The law sets achievable cost control targets and includes an array of reforms to the way healthcare is paid for and delivered. The Act, for example, develops Accountable Care Organizations, in which Medicare pays one provider to coordinate all of your healthcare successfully, as opposed to the current system that pays many doctors and providers to add to your care no matter the cost or outcome. It creates the Independent Payment Advisory Board (IPAB), a fifteen-member government agency which has the explicit task of implementing cost-controlling reforms across Medicare without congressional approval. And it goes after bad and wasted care – hospitals with high rates of re-admission, for example, will see a cut in payments. These types of reforms catalyze change and reward the value and quality of care, not just the quantity of care.
For a more thorough explanation on everything the law does, read the Kaiser Family Foundation’s excellent primer on the Act.
Whether or not these reforms will succeed is an open question, and there are a number of key metrics for establishing the success or failure (or both) in the years to come. As Sheila Burke and Elaine Kamarck recently wrote in an article for the Brookings Institute, key benchmarks for the Affordable Care Act include: (1) whether there is a reduction in the number of uninsured; (2) whether there is an increase or stabilization in the cost of premiums; (3) whether there are an adequate number of healthcare plans available in the exchanges; (4) whether the number of people who pay the penalty for not having insurance increases or decreases over time; (5) whether there is a decline in employer coverage; (6) whether there is a decline in full-time employment and an increase in part-time employment; (7) whether the conflict between federal and state oversight of health insurance increases or decreases over time; and (8) whether there is an increase or decrease in out-of-pocket expenditures on health care.
The success or failure of the Affordable Care Act, however, will not be measured by the performance of the program’s website. Technical issues on a website pale in comparison to the healthcare problems the Act genuinely attempts to address, problems the Republican Party seems unable or unwilling to recognize even exist. As President Obama remarked from the Rose Garden on Monday,
we did not wage this long and contentious battle just around a website. That’s not what this was about. We waged this battle to make sure that millions of Americans in the wealthiest nation on Earth finally have the same chance to get the same security of affordable quality health care as anybody else. That’s what this is about.
Indeed, Mr. President.