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How Will the Affordable Care Act Affect Patients with CHD?

Aprotinin Use in Europe: A personal view




How Will the Affordable Care Act Affect Patients with CHD?

By Randall Clark, MD
Children’s Hospital Colorado

The 2010 Patient Protection and Affordable Care Act (ACA) is a landmark piece of legislation that will touch every aspect of health care delivery in the United States.  Congenital cardiac anesthesiologists may ask how the ACA will impact them and the care they provide for patients, and how they might better prepare for a future heavily guided by the ACA.

The primary aim of the ACA is to bring better health care system access to tens of millions of uninsured US citizens by expanding the insurance market.  Its second aim is to bend the unsustainable cost curve for the expensive US health care delivery model.  Related to the second aim is the intention to reform payment for physicians and hospitals by changing the system from one that pays for individual services into one that pays for value and population health.

Several questions are obvious.  What follows is merely the opinion of this author. 

First, will the ACA affect the ability of patients with congenital heart disease (CHD) to receive care?  It is unlikely that the ACA will directly affect access by children with CHD into the health care system for the simple reason that existing insurance programs do a fairly good job of providing coverage.  Depending on the state, about 40-60% of children are covered by private health insurance and about 30 to 40% of all children are currently covered or are eligible for Medicaid or the state Children’s Health Insurance Program.  Children with CHD may qualify for Supplemental Security Income (SSI) under the Social Security Act.  SSI generally applies when a child has a severe functional impairment that is life threatening or lasts longer than 12 months.  In many circumstances SSI enrollment automatically qualifies a beneficiary for Medicaid.  Approximately half of the health care costs for children with CHD are billed to the Medicaid program.

The biggest change will likely occur for adults with congenital heart disease.  A significant and uniformly embraced change (except, perhaps, by insurance companies) is the substantial reform of private insurance rules.  Previously, patients with moderate or serious medical conditions would likely see astronomic prices for private insurance, if insurance was available at all.  The ACA prohibits insurance companies from denying insurance coverage on the basis of pre-existing conditions.  Patients with some conditions can be placed into higher rate bands but the price spread across the bands is far less (3 to 1) than prior to enactment of the ACA.  Significantly, insurance companies will be prohibited from imposing lifetime caps on insurance benefits.  While these caps frequently reached $1 million in the past, it is relatively easy for a patient with a complex cardiac problem, and many other health care problems, to exceed these caps.

Another change is difficult to gauge.  A fundamental aim of health care reform is to change the delivery model in the United States into one with much greater integration and emphasis on preventive care.  It is hoped that most patients, especially children, will be enrolled in “medical homes” or their equivalent, with broad-based programs focusing on population health.  If the medical home works as intended, there likely will be much greater attention paid to health maintenance and preventive care, including prenatal counseling.  How this impacts the incidence of congenital heart disease over time remains to be seen. 

There are unknown and potentially concerning aspects of the Affordable Care Act.  While notable for its length (over 1900 pages), the Act is relatively silent on the role of academic medical centers in health care reform.  Health care provided in academic medical centers tends to be more expensive than in other hospitals due to the added costs of the academic mission, including education and research.  If cost of care becomes the sole determinant of where care is received, academic centers may find themselves under extreme pressure.  On the bright side, there is every reason to believe that academic medical centers can address these challenges and continue their achievements in innovation, both in new and better therapies and in new thinking on how to shape the health care delivery system for the better.

Another aspect of this question must also be considered.  Care for patients with congenital heart disease is as expensive as it is challenging.  It is likely that physicians working in this area will be asked to justify the significant expense of providing this care.  It would be tragic if we lost all of the progress we have made in this area of medicine if the cost of care becomes the sole determinant of whether care should be offered at all.  To address this challenge, congenital cardiac anesthesiologists must become well versed in the “value” discussions coming our way.

The final matter to be considered is whether or not the significant financial assumptions in the Act will become reality.  Much of the ACA requires changes in human behaviors.  A good example is the relatively slow enrollment in the new health plans offered through the state exchanges, even with the substantial taxpayer-financed subsidies offered to families with as much as $95,000 in annual income.  If patients do not enroll, especially young patients with few health needs, the economic underpinnings of the Act will begin to fail.

On a broad scale, the ACA relies on large shifts in healthcare spending to keep its costs neutral.  Approximately $500 billion dollars of Medicare spending over the next ten years will need to be “saved” by a much more efficient and much more innovative delivery model.  This can be achieved if preventive care improves and we reduce the spending on care that does not materially improve the health of our patients, but the road to that future will be a difficult one to navigate.  Other cost-saving measures in that Act are already facing political pressure.  The only solution is for all participants in the system to value long-term system integrity over narrow interests, even if well intended.

The enactment of the Medicare program in 1965 was a major event in American history.  The passage of the Affordable Care Act will have even greater impact as it affects the entire health care system, both public and private, and citizens previously outside of these systems, the uninsured.  Congenital cardiac anesthesiologists will be greatly affected by the Act and will need to work tirelessly to create improvements in care that will benefit our patients and improvements in “value” that will benefit the health care system in its entirety.

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