Update on the Patient Protection and Affordable Care Act (PPACA): Good and bad

Update on the Patient Protection and Affordable Care Act (PPACA): Good and bad.

What was the base state before passage of PPACA in 2010?
Before considering the current state of health care after passage of PPACA, it is important to define the “base state”. Fortunately, baseline data are available from the 2010 national census concerning the health insurance status of Americans. According to the 2010 census, 16.3% of Americans had no health insurance, nearly 50 (49.9) million Americans! In 2010, Americans receiving health insurance from government increased slightly from prior years to 31%, 95 million Americans. That same year, Americans covered by employee-based health insurance decreased to 55%, 169 million Americans. These data represent the “base state” from the same year PPACA passed but before implementation. Physicians and scientists know how important it is to have such robust “before” data. As with any new law, there are “good” features that are very popular, and “bad” features that are not so popular.
THE GOOD. Although the naysayers will not admit it, there are very good provisions within PPACA. What are some of them? For a start, the PPACA broadens health insurance coverage for adults with pre-existing conditions and eliminates pre-existing conditions for children. Resolving this “pre-existing conditions” issue is long overdue! In addition, PPACA allows dependent children to remain on parents plan until age 26, an almost universally popular provision. The PPACA also ends rescissions, that is, insurance coverage cannot be cancelled because of a new illness. Now, there is also no lifetime dollar limit on coverage. Finally, the PPACA begins to address closure of the so-called Medicare drug donut hole. All of these changes are very positive improvements for many Americans. Importantly, there are now many more Americans with health insurance than before passage of PPACA—nearly 12 million more! These are some of the most positive changes resulting from implementation of PPACA.
THE BAD. Of course, no law is perfect. If you compare the 2016 census data with the numbers of newly insured Americans, there are at least 35 million Americans still without health insurance. Furthermore, in 2016, the penalty for not having health insurance increases significantly–to the higher of either $625/adult or 2.5% of household incomes. This is a potent penalty for those not complying with the PPACA provisions. According to CMS actuaries, health expenditures increased in 2014. Notably, the costs of hospital care, physicians’ services, prescription drugs and especially insurance premiums have all gone up. BUT the most striking increase is in the cost of government administration for health care—up 5-fold. More recently, from 2015 to 2016 insurance premiums on the ACA exchanges rose on average 9%. In 29 States, the average premium increases were in double digits and in one third of States the average premiums increased 20% or more. In addition to premium increases, there are increases in insurance deductibles. Silver plans, the most popular in the health care exchanges, now have an average deductible of nearly $3000 in 2016. Then there is the performance of the so-called “Obama care exchanges”. Fully 12 of the 23 cooperatives failed and are defunct. Of the remaining 11 cooperatives, 8 are under enhanced federal oversight or are on a corrective action plan. None of this is good news for Americans who counted on the cooperatives as a vehicle to sign up for health insurance. What does all this mean for patients wishing to use their health insurance? Can these patients really afford routine primary care or access to care for management of chronic disease? There are issues also of access to health care. Within PPACA, there was no plan to address the physician workforce, especially the ongoing shortage of primary care providers. For practicing physicians worried about medical malpractice, the PPACA failed to address tort reform in any meaningful way.
So there you have it—the mixed bag that is PPACA, both the good and the bad! Is it possible to keep the good while diminishing the bad? We shall see what the congress and new administration might propose after the elections in November. Stay tuned!