Discuss Medicare and Medicaid, the Affordable Care Act, and US Health Policy.

Opinion

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and not those o f the American Medical Association.

Medicare and Medicaid, the Affordable Care Act, and US Health Policy Howard Bauchner, MD

In 1965, Medicare and Medicaid transformed health care in the United States. Elderly, poor, and disabled individuals were guaranteed health insurance coverage, and with it access to physicians, hospitals, other services, and impor­ tant advances in medicine. Almost 50 years later, the Afford­ able Care Act (ACA) was introduced with the intent to ensure that all Americans are guaranteed health insurance coverage and with it access to a similar set of services. Although the introduction of Medicare and Medicaid was contentious and met with skepticism by many, including physicians, ulti­ mately it became embedded in US society. Whether the same will be true for the ACA remains unclear. This theme issue of JAMA is dedicated to recognizing 50 years of Medi­ care and Medicaid.

Medicare and Medicaid are huge programs. In a detailed comprehensive review of these programs, Altman and Frist1 describe both programs and how they have evolved over the last 5 decades. Currently, Medicare covers 55 million indi­ viduals and costs $585 million; Medicaid covers 66 million individuals and costs $449 million. Together these pro­ grams insure i l l million people, or 1 in 3 individuals in the United States. Whereas Medicare is a federal program, Medicaid is a shared responsibility of federal and state governments. At least for the foreseeable future and based on current assumptions, Medicare is financially stable, although these financial projections change every few years. The financial well-being of Medicaid is more of a challenge. Although the ACA (and the federal government) will support Medicaid expansion for the next few years, Medicaid now accounts for up to one-third of the budgets of some states, and given emerging new technologies and therapies, restraining the increase in health care costs will be a challenge.

Ascribing beneficial effects to health insurance has al­ ways been fraught with difficulty because few true experi­ ments have ever been conducted. Nevertheless, most people would prefer to have health insurance. In a review of the Medicare-eligible population over the past 15 years, Krumholz and colleagues2 describe numerous changes. Overall mortal­ ity among Medicare beneficiaries has declined from 5.30% in 1999 to 4 .45% in 2013. There has also been a decline in the total number of hospitalizations per too 000 person-years and a de­ crease in mean inflation-adjusted inpatient expenditures per Medicare fee-for-service beneficiary. Encouragingly, in the last 6 months of life, the number of hospitalizations, the percent­ age of beneficiaries with 1 or more hospitalizations, and the more recent data on inflation-adjusted inpatient expendi­

tures have also declined. These data suggest that end-of-life care in the United States may be changing.

The ACA has expanded health care coverage in the United States. Numerous reports indicate that between 12 million and 15 million individuals have been newly insured. Sommers and colleagues3 analyzed data collected between January 2012 and January 2015 from more than 500 000 adults who participated in the continuously fielded daily Gallup-Healthways Well-being Index. They found that com­ pared with the pre-ACA trend, the adjusted uninsured rate decreased 7.9 percentage points following implementation of the ACA. In addition, there were decreases in the percent­ age of respondents reporting lack of a personal physician, lack of easy access to medicine, and inability to afford care and decreases in the proportion of those reporting fair or poor health. Improvement in coverage was largest among minority groups; for example, the decrease in the uninsured rate was 11.9 percentage points among Latino adults and 10.8 percentage points among non-Latino black adults. Because of the size of the sample, the authors were also able to ana­ lyze the differences in the 28 states and District of Columbia that expanded Medicaid and 22 states that did not. The unin­ sured rate declined in all states, but a difference-in-difference analysis showed a greater reduction in the states that expanded Medicaid, with an overall decline of 5.2 per­ centage points. The ACA is successfully meeting one of its goals, extending health care to more Americans.

A major goal of the Centers for Medicare & Medicaid Ser­ vices is to incentivize high-quality care. In an analysis of the Hospital-Acquired Condition Reduction Program that reduces payments to hospitals that perform poorly on vari­ ous measures, Rajaram and colleagues4 found that hospital­izations were more likely to be penalized if they were accredited by the Joint Commission, were a major teaching hospital, cared for patients with complex injury or illness, and were a safety-net hospital. In addition, on an externally validated summary measure of hospital quality, they found that hospitals with the highest-quality scores were signifi­ cantly more likely to be penalized than hospitals with lowest-quality scores (67.3% vs 12.6%). These data highlight how difficult it is to assess the quality of hospital care and show that the measures used by the Hospital-Acquired Con­ dition Reduction Program may not be appropriate. Given that measuring quality is a centerpiece for many of the initia­ tives of the CMS and that a substantial amount of reimburse­ ment is at risk, more work may be needed to validate mea­ sures of quality.

jama.com JAMA July 28,2015 Volume 314, Number 4 353

Opinion Editorial

Nine scholarly Viewpoints in this issue of JAMA discuss various aspects of current US health care policy. Gostin and colleagues5 report on the recent King v Burwell decision, the initial goals of the ACA, the various legal challenges, what the ACA has accomplished, and remaining challenges focusing on further increasing coverage for the near poor, poor, and undocumented immigrants. Butler,6 Cutler,7 and Wilensky8 provide insightful perspectives and suggestions about how the ACA should be modified to be successful. As discussed by Altman and Frist,1 Medicare and Medicaid have constantly evolved since 1965. Clough and colleagues9 describe emerg­ ing alternative payment models in fee-for-service Medicare. Mann and Osius10 and Bindman11 reflect on Medicaid, reviewing its current status and future challenges. Boozary and Senators Manchin and Wicker12 argue that the CMS should consider socioeconomic status when calculating pen­ alties related to readmissions because safety-net hospitals are being unfairly penalized. Hwang and colleagues13 review many of the important innovations that have begun at the state level; for example, Maryland has eliminated fee-for- service payment to hospitals and Arkansas and Tennessee are experimenting with bundled payments. This type of “local” innovation in health care delivery maybe more acceptable than policy dictated in Washington. One of the remarkable aspects of the United States is the ability to innovate, and this is generally true in most aspects of society, including health care. Although the US has lagged behind other resource-rich nations in extending health care to all of its citizens, the ACA, Medicaid expansion, and other health care delivery models represent creative and innovative ways to try to accomplish this goal.

The future of health care delivery in the United States faces many challenges, as frequently discussed in other View­ points and other articles that regularly appear in JAMA. The commitment of moving from volume-based reimbursement to value-based reimbursement should continue. Diagnostic and therapeutic advances must be available to everyone and not exacerbate but rather ameliorate health care disparities. End- of-life care should be transformed and be more patient fo­ cused. (Sadly, most physicians have their own personal sto­ ries of how the health care system has failed their own family members at end of life.) Reducing waste and inappropriate care is critical so that those savings can be used to support new therapies, many of which will be expensive. The quality- improvement movement needs to be reinvigorated by pars­ ing the number of measures and focusing on those that are likely to lead to the largest gains in health. The spirit of pro­ fessionalism that has so long served physicians well must be recaptured. And the administrative burden on practicing phy­ sicians must be reduced so that they can spend more time com- municating with their patients and providing patient- centered care.

Just as Medicare and Medicaid have evolved over the past 50 years to become critically important and indispensable ele­ ments of the health care system, the ACA must continue to evolve. Both political parties appear to be committed to en­ suring that all Americans have access to health care-be that as a right or as a privilege. Legal and political challenges to the ACA will continue. They are an inevitable part of the US po­ litical landscape, but challenges to the ACA must be accom­ panied by other ideas that will ensure that all Americans have access to high-quality, affordable, health care.

ARTICLE INFORMATION

Author Affiliation: Editor in Chief, JAMA.

Corresponding Author: Howard Bauchner, MD, Editor in Chief, JAMA. 330 N Wabash Ave, Chicago, IL 60611 (howard.bauchner@jamanetwork.org).

Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure o f Potential Conflicts o f Interest and none were reported.

REFERENCES

1. Altman D, Frist WH. Medicare and Medicaid at 50 years: perspectives of beneficiaries, health care professionals and institutions, and policy makers. JAMA. doi:10.1001/jama.2015.7811.

2. Krumholz HM, Nuti SV, Downing NS, Normand S-LT, WangY. Mortality, hospitalizations, and expenditures for the Medicare population aged 65 years and older, 1999-2013. JAMA. doi:10.1001/jama .2015.8035.

3. Sommers BD, Gunja MZ, Finegold K, Musco T. Changes in self-reported insurance coverage, access to care, and health under the Affordable Care Act. JAMA. doi:l0.100l/jama.2015.842l.

4. Rajaram R, Chung JW, Kinnier CV, et al. Hospital characteristics associated with penalties in the Centers for Medicare & Medicaid Services Hospital-Acquired Condition Reduction Program. JAMA. doi:10.1001/jama.2015.8609.

5. Gostin L, DeBartolo MC, Hougendobler DA. King v Burwell: subsidizing US health insurance for low- and middle-income individuals. JAMA. doi:10 .1001/jama.2015.8673.

6. Butler SM. Strengthening the Affordable Care Act: the need for strategic building blocks. JAMA. doi:l0.1001/jama.2015.7153.

7. Cutler D. From the Affordable Care Act to affordable care. JAMA. doi:10.1001/jama.2015.7683.

8. Wilensky GR. Improving and refining the Affordable Care Act. JAMA. doi:10.1001/jama.2015 .5468.

9. Clough JD, Richman BD, Glickman SW. Outlook for alternative payment models in fee-for-service Medicare. JAMA. doi:10.100l/jama.20l5.8047.

10. Mann C, Osius E. Medicaid’s new role in the health care system. JAMA. doi:10.1001/jama.2015 .8433.

11. Bindman AB. Managing the future of Medicaid. JAMA. doi:10.1001/jama.2015.8209.

12. Boozary AS, Manchin J III. Wicker RF. The Medicare hospital readmissions reduction program: time for reform. JAMA. doi:10.1001/jama.2015.6507.

13. Hwang A, Sharfstein JM, KollerCF. State leadership in health care transformation: red and blue. JAMA. doi:10.1001/jama.2015.8211.

354 JAMA July 28,2015 Volume 314, Number 4 jama.commailto:howard.bauchner@jamanetwork.org

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