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The Affordable Care Act at 10 Years: Evaluating the Evidence and Navigating an Uncertain Future

  • Pooja U. Neiman
    Affiliations
    Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts

    National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan

    Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
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  • Thomas C. Tsai
    Affiliations
    Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts

    Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
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  • Regan W. Bergmark
    Affiliations
    Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts

    Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
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  • Andrew Ibrahim
    Affiliations
    Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan

    Department of Surgery, University of Michigan, Ann Arbor, Michigan
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  • Hari Nathan
    Affiliations
    Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan

    Department of Surgery, University of Michigan, Ann Arbor, Michigan
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  • John W. Scott
    Correspondence
    Corresponding author. Department of Surgery, University of Michigan, CHOP, 2800 Plymouth Road, NCRC, Building 16, Ann Arbor, MI 48109. Tel.: +1 734 936 2661; fax: +1 734 615 1054.
    Affiliations
    Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan

    Department of Surgery, University of Michigan, Ann Arbor, Michigan
    Search for articles by this author
Published:February 25, 2021DOI:https://doi.org/10.1016/j.jss.2020.12.056

      Abstract

      The year 2020 marks the 10th anniversary of the signing of the Affordable Care Act (ACA). Perhaps the greatest overhaul of the US health care system in the past 50 y, the ACA sought to expand access to care, improve quality, and reduce health care costs. Over the past decade, there have been a number of challenges and changes to the law, which remains in evolution. While the ACA's policies were not intended to specifically target surgical care, surgical patients, surgeons, and the health systems within which they function have all been greatly affected. This article aims to provide a brief overview of the impact of the ACA on surgical patients in reference to its tripartite aim of improving access, improving quality, and reducing costs.
      March 23rd, 2020, marked the 10th anniversary signing of the Affordable Care Act (ACA). In these times of economic uncertainty and unprecedented unemployment,
      Health insurance coverage of the total population. KFF.
      the most sweeping health reform law in the last few decades remains as relevant as ever. This federal statute was the largest comprehensive health care legislation since Medicare and Medicaid were established in 1965 and was created with three goals: 1) to increase access, 2) to improve quality, and 3) to reduce costs (Fig. 1). Its main vehicle to increase access was by expanding both private and public health insurance coverage. It sought to improve quality by linking hospital and physician payments to the quality of care they provide. It looked to reduce costs by investing in new patient care models, such as bundled payments. The ACA has made headway in all three goals but has also faced challenges in legislation, funding, and support. Although often thought of as a single policy, the ACA consists of multiple policies that work together toward different goals. These goals, although not initially intended to impact surgical care directly, effects surgical patients, surgeons, and the health systems they function within. This article aims to provide a brief overview of the impact of the ACA on surgical patients in reference to the tripartite aim of improving access, improving quality, and reducing costs (Table).
      Figure thumbnail gr1
      Fig. 1The 3 pillars of the Affordable Care Act (ACA): access, quality, and cost. The ACA increased access by increasing access to health insurance (employer-based and the Marketplaces for private insurance, Medicaid expansion for public insurance, and all children under the age of 26 years could stay on their parent's insurance). It increased quality by linking payments to quality (Accountable Care Organizations (ACOs), Medicare Shared Savings Program (MSSP), and Hospital Readmissions Reduction Program). It decreased costs through new patient care models (Bundled Payment for Care Improvement Program). Icon credits: Gregor Cresnar, The Icon Z, Arthur Shlain from the Noun Project. (Color version of figure is available online.)
      TableSummary of the ACA, surgery, and the pandemic.
      Key questionsKey findingsSources
      How successful was the ACA at expanding insurance coverage and timely access to care among surgical populations?
      • Earlier presentation for acute surgical diseases.
      • Improved cancer screening and earlier stage at diagnosis.
      • Increased listing for heart and lung transplant.
      • Increased access to rehab after trauma.
      • No inpatient mortality benefits identified.
      Loehrer et al. JAMA Surg 2018

      Zogg et al. JACS 2018

      Eslami et al. Ann Surg 2019

      Zerhouni et al. DCR 2019

      Ajkay et al. JACS 2018

      Sineshaw et al. JAMA Oto 2020

      Hyanga et al. Transpl Int'l 2019

      Scott et al. J trauma 2019

      Zogg et al. JAMA surgery 2019
      Did the ACA impact prepolicy racial/ethnic disparities in insurance coverage or clinical outcomes among surgical populations?
      • Racial/ethnic insurance coverage gap decreased.
      • Uninsured rate among non-Hispanic black and Hispanic populations decreased in both Medicaid expansion and nonexpansion states.
      • Black adults achieved similar coverage rates to white adults in expansion states.
      • Black and Hispanic patients had a greater reduction in ruptured appendicitis rates, a proxy for timely access to care.
      • Almost 50% of black adults and 1/3 of Hispanic adults live in states that have not yet expanded Medicaid.
      Baumgartner et al. Commonwealth Fund 2020

      Baumgartner et al. AM J PH 2016

      Zogg et al. Ann Surg 2018
      How has the ACA improved the quality of the health care delivered?
      • The Medicare Shared Savings Program (MSSP) encouraged creation of accountable care organizations (ACOs) and tracking of outcomes.
      • From 2012 to 2014, ACO hospitals cost the health care system $100 million, but ACO physician groups saved $250 million.
      • MSSP did not focus on surgical care, and no change in cost or quality of various surgical metrics has been shown.
      • ACOs are taking on increasing downside risk (monetary penalties for poor performance)
      Muhlestein et al. HA 2019

      McWilliams et al. NEJM 2018

      Nathan et al. Ann Sug 2019

      Herrel et al. Cancer 2016

      Resnick et al. Ann Surg 2018
      Has the ACA reduced health care costs?
      • Higher quality hospitals spend less on surgical care.
      • For bariatric surgery, lowest readmission rates and complication rates among hospitals that spend less—bundled payments saved the health care system $200M
      • The Hospital Readmission Reduction Program decreased readmission rates overall, but consequences and impact size are still being evaluated
      Tsai et al. HA 2016

      Tsai et al. JAMA Surg 2015

      Chandra et al. HA 2013

      Chhabra et al. Ann Surg 2019

      Ibrahim et al. Ann Surg 2017

      Demiralp et al. HSR 2018

      Ibrahim et al. JAMA IM 2017

      Lindrooth et al. HA 2018

      Sommers et al. HA 2017

      Lie et al. JAMA open 2020
      What are the threats to the future of the ACA?
      • Funding cut since 2016: Patient navigator funding dropped by $55 million, advertising budget cut 90%.
      • Uninsured rate increased almost 4% from 2016 to 2018 (1.2 M nonelderly adults).
      • Voters continue to expand Medicaid via state ballot bills.
      • However, many states are reducing enrollment through work restrictions and other policies.
      • COVID-19 stopped these restrictions given surge in unemployment and loss of employer-based health insurance.
      • Now seeing push from states to expand Medicaid eligibility and private insurance companies preparing for increased enrollment.
      Kliff et al. KFF 2020

      Tolbert et al. KFF 2020

      Keith. HA Blog 2019

      Fehr. KFF 2020
      Summary of the ACA, surgery, and the pandemic.

      The ACA's impact on access to surgical care

      One of the primary aims of the ACA was to reduce the number of Americans who are uninsured. It did this through the extension of private and public health insurance. The ACA expanded private insurance through two main mechanisms: employer-based insurance reform measures and the creation of online health insurance Marketplaces.
      • Orgera K.
      Jan 25 ADP, 2019. The uninsured and the ACA: a primer – key facts about health insurance and the uninsured amidst changes to the affordable care Act - how have health insurance coverage options and availability changed under the ACA? KFF.
      Approximately, half of all US residents have health insurance through their employer, making employer-based insurance the most common form of insurance.
      Health insurance coverage of the total population. KFF.
      For those who do not have this, the health insurance Marketplaces are available, supported by tax credits on premiums and subsidies on cost sharing.
      • Pollitz K.
      Apr 18 GCP, 2018. Proposals for insurance options that don’t comply with ACA rules: trade-offs in cost and regulation. KFF.
      Insurance expansion also allowed children to continue under their parents’ insurance up until they are 26 y old and required all insurance policies to cover 100% of preventative costs. By expanding health insurance coverage, 17 million people who were previously uninsured gained health insurance within 1 y of implementation of the ACA—from 2014 to 2015.
      • Carman K.G.
      • Eibner C.
      • Paddock S.M.
      Trends in health insurance enrollment, 2013–15.
      Medicaid expansion was a large component of the ACA and its goal was to increase access to health care for lower income adults. It expanded public insurance by expanding eligibility for enrollment in Medicaid to 138% of the federal poverty line from 44%.
      • Orgera K.
      Jan 25 ADP, 2019. The uninsured and the ACA: a primer – key facts about health insurance and the uninsured amidst changes to the affordable care Act - how have health insurance coverage options and availability changed under the ACA? KFF.
      Medicaid expansion was initially federally mandated, but in 2012 the Supreme Court ruled that the federal government could not force states to expand insurance given Medicaid is a state-based program. Despite this, 25 states were the first to expand Medicaid by January 1, 2014, and more states have expanded since—6 of which (ID, UT, NE, OK, MO, ME) have performed so with voter-led state ballot initiatives.
      • Kliff S.
      How progressives flipped the script on Medicaid expansion. The New York Times.
      ,
      • Mitchell A.
      As of today, 39 states and DC have expanded Medicaid (OH and MO have passed expansion laws but are not yet implemented) (Fig. 2).
      KFF
      Status of state Medicaid expansion Decisions: interactive map.
      Figure thumbnail gr2
      Fig. 2Status of state Medicaid expansion decisions. 39 states and D.C. have passed laws to expand Medicaid, 12 have not. OK and MO have passed Medicaid Expansion laws but have not implemented them, resulting in 15 states that have not implemented Medicaid Expansion. Data adapted from the Kaiser Family Foundation, Status of State Action on the Medicaid Expansion Decision, updated on August 5th, 2020. Created with MapChart.net. (Color version of figure is available online.)
      Medicaid expansion helped mitigate the gap in health care outcomes and disparities in health-related financial hardship.
      • Baumgartner J.
      How ACA Narrowed Racial Ethnic Disparities Access to Health Care.
      ,
      • Buchmueller T.C.
      • Levinson Z.M.
      • Levy H.G.
      • Wolfe B.L.
      Effect of the affordable care Act on racial and ethnic disparities in health insurance coverage.
      Nationally, the gap in insurance coverage between black and white patients and between Hispanic/Latino
      ThinkNow
      Progressive Latino pollster: trust me. Latinos do not identify with “Latinx.” Medium.
      and white patients decreased.
      • Baumgartner J.
      How ACA Narrowed Racial Ethnic Disparities Access to Health Care.
      Notably, racial/ethnic disparities in insurance status were reduced in both Medicaid expansion and nonexpansion states.
      • Baumgartner J.
      How ACA Narrowed Racial Ethnic Disparities Access to Health Care.
      In expansion states, white, black, and Hispanic patients all had improved coverage, with black adults in expansion states achieving coverage levels similar to white adults in nonexpansion states.
      • Baumgartner J.
      How ACA Narrowed Racial Ethnic Disparities Access to Health Care.
      Nationally, the ACA's improvements in health insurance coverage have translated to improved health care access for surgical populations. After the implementation of the ACA, surgical patients presented to a care center earlier for acute surgical diseases such as appendicitis, cholecystitis, acute limb ischemia, and colon cancer perforation.
      • Liu C.
      • Tsugawa Y.
      • Weiser T.G.
      • Scott J.W.
      • Spain D.A.
      • Maggard-Gibbons M.
      Association of the US affordable care Act with out-of-pocket spending and catastrophic health expenditures among adult patients with traumatic injury.
      • Zerhouni Y.A.
      • Scott J.W.
      • Ta C.
      • et al.
      Impact of the affordable care Act on trauma and emergency general surgery: an Eastern association for the surgery of trauma systematic review and meta-analysis.
      • Eslami M.H.
      • Dakour-Aridi H.
      • Avgerinos E.D.
      • Makaroun M.S.
      • Malas M.B.
      Vascular Quality Initiative
      Impact of Medicaid expansion of the affordable care on the outcomes of lower extremity bypass for patients with peripheral artery disease in the vascular quality initiative database.
      This results in fewer perforated appendices, fewer laparoscopic converted to open cholecystectomies, and fewer limb amputations. In particular for states that expanded Medicaid, the uninsured rate of the trauma patient population decreased by 16 percentage points, from 22.7% to 6.8%.9 Cancer screening was also improved, leading to earlier stage at initial diagnosis—for example, head and neck cancer patients in Medicaid expansion states showed a 25% reduction in time to treatment initiation.10 There are also increased listings for heart and lung transplants and increased access to rehab centers after trauma.11,12
      Disparities in access to surgical care decreased as health insurance expansion improved access to medical care. For example, the rate of perforated appendicitis among black and Hispanic patients improved disproportionately compared with white patients. In addition, early studies suggest that patients in Medicaid expansion states are presenting with earlier stage cancers.
      • Sineshaw H.M.
      • Ellis M.A.
      • Yabroff K.R.
      • et al.
      Association of Medicaid expansion under the affordable care Act with stage at diagnosis and time to treatment initiation for patients with head and neck squamous cell carcinoma.
      However, 46% of Black adults and approximately one-third of Hispanic adults are in the 15 states (primarily in the South) that have thus far not implemented Medicaid expansion.
      • Baumgartner J.
      How ACA Narrowed Racial Ethnic Disparities Access to Health Care.
      There are insufficient data at this time to determine the effects on racial/ethnic disparities on quality of care or financial risk for surgical care. More data are needed regarding what care and where the care is being obtained for these minority patients.
      To date, these improvements in access to timely surgical care have not yet demonstrated inpatient mortality differences. This is also true of nonsurgical conditions as well. However, population-level analyses suggest that the impact on overall mortality has been 15-30 fewer deaths per 100,000 patients.
      • Zerhouni Y.A.
      • Scott J.W.
      • Ta C.
      • et al.
      Impact of the affordable care Act on trauma and emergency general surgery: an Eastern association for the surgery of trauma systematic review and meta-analysis.
      ,
      • Manzano-Nunez R.
      • Zogg C.K.
      • Bhulani N.
      • et al.
      Association of Medicaid expansion policy with outcomes in homeless patients requiring emergency general surgery.
      • Wadhera R.K.
      • Bhatt D.L.
      • Wang T.Y.
      • et al.
      Association of state Medicaid expansion with quality of care and outcomes for low-income patients hospitalized with acute myocardial infarction.
      • Wadhera R.K.
      • Joynt Maddox K.E.
      • Fonarow G.C.
      • et al.
      Association of the affordable care act’s Medicaid expansion with care quality and outcomes for low-income patients hospitalized with heart failure.
      • Frean M.
      • Gruber J.
      • Sommers B.D.
      Premium subsidies, the mandate, and Medicaid expansion: coverage effects of the affordable care Act.
      • Miller S.
      • Altekruse S.
      • Johnson N.
      • Wherry L.R.
      Medicaid and Mortality: New Evidence from Linked Survey and Administrative Data.
      These findings further emphasize that the health of surgical patients may be more reliant on access to outpatient services than inpatient.

      The ACA's impact on surgical quality

      The ACA worked to improve health outcomes of all patients by strengthening accountable care organizations (ACOs). ACOs are groups of doctors, hospitals, and other health care providers who voluntarily come together to give coordinated, high-quality care. There are over 1000 ACOs that cover 45 million patients across the US and Medicare ACOs account for $85 billion in annual spending.
      • Muhlestein D.
      • Bleser W.K.
      • Saunders R.S.
      • Richards R.
      • Singletary E.
      • McClellan M.B.
      Spread of ACOs and value-based payment models in 2019: gauging the impact of pathways to success | health affairs.
      To encourage groups of physicians and hospitals to form ACOs and track their outcomes, the ACA created the Medicare Shared Savings Program (MSSP), a program of the Center for Medicare and Medicaid Services (CMS). Participation in MSSP is incentive-based and the goal is to gather data for all aspects of health care at a population level to improve outcomes and curb costs—but in turn, take on more monetary penalties for poor performance. This is termed, downside risk. Data from the 2012-2014 MSSP showed that hospital-integrated ACOs saved $121 million but earned $232 million in bonus payments (costing the health care system over $100 million), but physician group ACOs saved $583 million and earned $327 million in bonus payments (net savings of $256 million).
      • McWilliams J.M.
      • Hatfield L.A.
      • Landon B.E.
      • Hamed P.
      • Chernew M.E.
      Medicare spending after 3 Years of the Medicare shared savings program.
      The ACOs which are the highest performing are those that participate in MSSP, focus on continuous performance improvement in quality, and have below average baseline spending.

      US Department of Health and Human Services. Medicare Shared Savings Program Accountable Care Organizations Have Shown Potential for Reducing Spending and Improving Quality (OEI-02-15-00450; 08/17). Available at: https://oig.hhs.gov/oei/reports/oei-02-15-00450.asp. Accessed 1 February 2021.

      MSSP did not focus on surgical care, but some surgical quality data are emerging. Between 2010 and 2014, there has been no change in cost or quality of surgical care within these ACOs (six procedures: AAA repair, colectomy, coronary artery bypass grafting, total hip, total knee, and lung resection).
      • Nathan H.
      • Thumma J.R.
      • Ryan A.M.
      • Dimick J.B.
      Early impact of Medicare accountable care organizations on inpatient surgical spending.
      There was also no change in cancer surgery outcomes or decrease in low-value surgeries such as knee arthroplasties.
      • Herrel L.A.
      • Norton E.C.
      • Hawken S.R.
      • Ye Z.
      • Hollenbeck B.K.
      • Miller D.C.
      Early impact of Medicare accountable care organizations on cancer surgery outcomes.
      Although this is partly due to only 22% of surgeons participated in MSSP ACOs, more data need to be collected for surgical care through MSSP.
      • Muhlestein D.
      • Bleser W.K.
      • Saunders R.S.
      • Richards R.
      • Singletary E.
      • McClellan M.B.
      Spread of ACOs and value-based payment models in 2019: gauging the impact of pathways to success | health affairs.
      However, it is notably becoming a legacy program with several other Medicare ACO models now in existence.
      • Muhlestein D.
      • Bleser W.K.
      • Saunders R.S.
      • Richards R.
      • Singletary E.
      • McClellan M.B.
      Spread of ACOs and value-based payment models in 2019: gauging the impact of pathways to success | health affairs.
      ,,
      • Resnick M.J.
      • Graves A.J.
      • Buntin M.B.
      • Richards M.R.
      • Penson D.F.
      Surgeon participation in early accountable care organizations.
      A third ACA-related quality program that is relevant to surgical patients is the Hospital Readmissions Reduction Program. This program is a Medicare value–based purchasing program that reduces payments to hospitals with excess readmissions. The goal is to improve health care by linking payment to the quality of hospital care.
      • Pollitz K.
      Apr 18 GCP, 2018. Proposals for insurance options that don’t comply with ACA rules: trade-offs in cost and regulation. KFF.
      The latest data from the program shows that it not only decreased readmission rates for the conditions targeted (acute myocardial infarction, chronic obstructive pulmonary disease, pneumonia, coronary artery bypass grafting, and total hip and knee arthroplasties) but also had spillover effects for other conditions.
      • Wadhera R.K.
      • Yeh R.W.
      • Joynt Maddox K.E.
      The hospital readmissions reduction program - time for a reboot.
      • Ibrahim A.M.
      • Nathan H.
      • Thumma J.R.
      • Dimick J.B.
      Impact of the hospital readmission reduction program on surgical readmissions among Medicare beneficiaries.
      • Demiralp B.
      • He F.
      • Koenig L.
      Further evidence on the system-Wide effects of the hospital readmissions reduction program.
      However, the unintended consequences of increased mortality in some of the targeted conditions are still being evaluated. Moreover, there is evidence that coding artifact—CMS in 2011 changed total number of comorbidities from 10 to 25—may have impacted risk adjustment and overestimated the impact of the Hospital Readmissions Reduction Program by as much as half.
      • Ibrahim A.M.
      • Dimick J.B.
      • Sinha S.S.
      • Hollingsworth J.M.
      • Nuliyalu U.
      • Ryan A.M.
      Association of coded severity with readmission reduction after the hospital readmissions reduction program.
      ,
      • Ody C.
      • Msall L.
      • Dafny L.S.
      • Grabowski D.C.
      • Cutler D.M.
      Decreases in readmissions credited to medicare’s program to reduce hospital readmissions have been overstated.

      The ACA's impact on surgical cost reduction

      The ACA sought to reduce costs through programs that shifted the focus from volume to value through alternative payment programs such as bundled payments. Bundled payments are a method of reimbursing providers or facilities for an entire episode of care—for example, a hospital would receive one reimbursement for all costs associated with a laparoscopic appendectomy instead of separate reimbursements for the antibiotics, anesthesia, OR time, etc. The Bundled Payment for Care Improvement Program was created to curb spending variation between hospitals.
      Bundled payments for care improvement (BPCI) initiative: general information.
      ,
      • Tsai T.C.
      • Greaves F.
      • Zheng J.
      • Orav E.J.
      • Zinner M.J.
      • Jha A.K.
      Better patient care at high-quality hospitals may save Medicare money and bolster episode-based payment models.
      Prior research has revealed that postacute care accounts for most of this spending variation, as well as the growth of spending over time.
      • Tsai T.C.
      • Miller D.C.
      Bundling payments for episodes of surgical care.
      ,
      • Chandra A.
      • Dalton M.A.
      • Holmes J.
      Large increases in spending on postacute care in Medicare point to the potential for cost savings in these settings.
      Furthermore, data show that higher quality hospitals spend less on postacute care and readmissions, which serve as spending and readmission targets.
      • Tsai T.C.
      • Greaves F.
      • Zheng J.
      • Orav E.J.
      • Zinner M.J.
      • Jha A.K.
      Better patient care at high-quality hospitals may save Medicare money and bolster episode-based payment models.
      These decreased expenditures also apply to surgical subspecialities.
      • Dummit L.
      • Marrufo G.
      • Marshall J.
      • et al.
      The Lewin Group
      CMS bundled payments for care improvement initiative models 2-4: year 5 evaluation & monitoring annual report.
      ,
      • Chhabra K.R.
      • Sheetz K.H.
      • Regenbogen S.E.
      • Dimick J.B.
      • Nathan H.
      Wide variation in surgical spending within hospital systems: a missed opportunity for bundled payment success.
      Specifically within bariatric surgery, the lowest spenders are also the practices that have the lowest 90-day readmission rate and complication rate.
      • Chhabra K.R.
      • Sheetz K.H.
      • Regenbogen S.E.
      • Dimick J.B.
      • Nathan H.
      Wide variation in surgical spending within hospital systems: a missed opportunity for bundled payment success.
      Through the Bundled Payment program, spending by hospitals decreased by $278.5 million, spending by physician group practices decreased by $255 million, and there was a net savings to CMS of $202 million after accounting for incentive payments.
      • Dummit L.
      • Marrufo G.
      • Marshall J.
      • et al.
      The Lewin Group
      CMS bundled payments for care improvement initiative models 2-4: year 5 evaluation & monitoring annual report.
      To scale bundled payments into wider health system transformation, a potential path forward could focus on surgical conditions, mandatory participation by hospitals and physicians groups, and increased downside risk.
      One concern with the ACA's focus on reducing costs has been that reduced payments to hospitals and physicians could reduce the financial solvency of hospitals and therefore lead to hospital closures. However, these cost reduction programs through Medicaid expansion have led to a 30% increase in margins for uncompensated care and a six times lower risk of hospital closure for hospitals in expansion states.
      • Lindrooth R.C.
      • Perraillon M.C.
      • Hardy R.Y.
      • Tung G.J.
      Understanding the relationship between Medicaid expansions and hospital closures.

      Challenges to the ACA

      Since 2016, there has been a large deinvestment in the ACA—the ACA's advertising budget was cut by 90% in 2017
      • Kliff S.
      Trump is slashing Obamacare’s advertising budget by 90%. Vox.
      and funding for patient navigators (those that helped individuals register for health insurance) dropped to $10 million from $65 million.
      • Pollitz K.
      • Tolbert J.
      Nov 13 MDP, 2019. Data Note: limited navigator funding for federal marketplace states. KFF.
      ,
      • Inserro A.
      CMS cuts budget for ACA marketing to $10 million for 2019 plan Year. AJMC.
      These funding cuts, and the rhetoric of repealing the ACA, have resulted in increasing uninsured rates.
      • Scott D.
      The Trump administration’s latest steps to undermine the Affordable Care Act, explained. Vox.
      After the US uninsured rate for nonelderly adults reached its all-time nadir of 10% in 2016, it increased to 13.7% by 2018 resulting in 1.7 million more uninsured adults.
      • Tolbert J.
      • Orgera K.
      • Singer N.
      Dec 13 ADP, 2019. Key facts about the uninsured population. KFF.
      ,
      • Keith K.
      Uninsured rate rose in 2018, says census bureau report | health affairs.
      This increase in the uninsured rate has disproportionately affected young adults, Hispanics, low-income people, and those earning $125-150k per year.
      • Keith K.
      Uninsured rate rose in 2018, says census bureau report | health affairs.
      In addition, in December 2017, the Supreme Court repealed the so-called “individual mandate” that originally penalized taxpayers if they did not obtain health insurance the year prior. 2019 was the first year the repeal was implemented and despite the worries that the health insurance marketplaces would enter a “death spiral,”
      • Gabel J.
      • Whitmore H.
      The marketplace premiums increase: underwriting cycle or death spiral? | Health Affairs.
      results from the first 9 mo of 2019 suggest that the individual market remains profitable and stable.
      • Fehr R.
      Individual insurance market performance in late 2019. The henry J. Kaiser family foundation.
      It is impossible to evaluate the future of the ACA without taking the coronavirus disease 2019 (COVID-19) pandemic into consideration. As the current pandemic progresses, the need for health insurance coverage has increased—not only for those uninsured before the pandemic, but also for the newly unemployed who have lost their employer-based insurance coverage. It is estimated that 12 to 35 million people could lose their workplace coverage due to layoffs during the coronavirus shutdown—in fact, 5.4 million people lost their employer-based health insurance between February and May 2020.
      First, The coronavirus pandemic took their jobs. Then, it wiped out their health insurance. - the Washington Post.
      ,
      • Gangopadhyaya A.
      • Garrett A.B.
      Unemployment, health insurance, and the COVID-19 recession.
      In addition, there are threats to state-level Medicaid expansion. Before the COVID-19 outbreak, various state governments pursued additional eligibility and verification requirements to obtain Medicaid. These changes affected not only current Medicaid beneficiaries but also the estimated 6.7 million uninsured individuals who were eligible for Medicaid.
      Distribution of eligibility for ACA health coverage among those remaining uninsured as of 2018. The Henry J Kaiser Family Foundation.
      Earlier this year, these work restrictions were paused given the state of emergency as well as Court of Appeals’ rulings that work requirements are unlawful.
      • Musumeci M.B.
      3 key Questions about the Arkansas Medicaid work and reporting requirements case. KFF.
      How states are facilitating Medicaid enrollment during COVID-19—and how they can do even more | health affairs.
      Utah suspends Medicaid work requirement due to COVID-19. Modern Healthcare.
      However, in mid-October, the state of Georgia was granted permission to initiate work requirements for their Medicaid enrollees by the CMS.
      Trump administration approves innovative state-led health reform to expand and strengthen coverage for Georgia residents | CMS.
      Unfortunately, work requirement policies such as these may ultimately place a barrier for low-income Americans to qualify for affordable health insurance—especially as unemployment rates increase.
      • Sommers B.D.
      • Fry C.E.
      • Blendon R.J.
      • Epstein A.M.
      New approaches in Medicaid: work requirements, health savings accounts, and health care access.
      In response to these recent threats to the ACA's progress in increasing health insurance coverage, there appears to be resurgence of action from individual states and Congress to instead expand eligibility, expedite enrollment, promote continuity of coverage, and facilitate access to care. Furthermore, private insurance companies such as Anthem, Centene, Cigna, Molina Healthcare, UnitedHealth Group, and the Aetna unit of CVS Health are preparing for a large influx of US citizens through the health insurance Marketplaces as employers are cutting health benefits.
      • Japsen B.
      Insurers brace for big influx of Jobless Americans to obamacare and Medicaid. Forbes.
      The COVID-19 pandemic is considered the ACA's largest test, and it has largely galvanized support for the ACA.

      Where to go from here?

      Despite the ongoing challenges to many of its core policies, the ACA currently remains in place and its impact on surgical patients is clear. The ACA led to a significant reduction in the uninsured rate across a variety of surgical populations. The ACA has led to improved quality and fewer readmissions. The ACA has also been associated with improved hospital margins and a significant reduction in the risk that a patient might experience catastrophic financial consequences as a result of emergency surgery. And, while not all populations benefitted equally, the ACA made some strides in reducing long-standing inequalities in health care. Despite these gains, many of the ACA's policies have faced and continue to face challenges in courts and legislative bodies. Furthermore, the rise in unemployment that has accompanied the ongoing COVID-19 pandemic places patients at even more at risk of losing health insurance coverage. The evidence highlighted in this review helps improve our understanding of what aspects of the ACA have worked and what aspects have fallen short. But ongoing policy evaluation is critically important to ensure that we also understand the ramifications of policy changes that threaten to undo some of the progress made in the last decade. Just as the ACA's benefits did not impact all members of society equally, the policy changes that curtail some of the ACA's benefits will disproportionally impact some. There has never been a more important time to ensure that we are all working to optimize access to timely, equitable, high quality, affordable surgical care for everyone.

      Disclosure

      The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.

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