The Patient Protection and Affordable Care Act Six Years Later Are We Healthier? Has the Quality of Care Improved? by Barry Liss T he Patient Protec- tion and Affordable Care Act has a wide array of provisions intended to improve health and the qual- ity of care. 1 In addition to expanding health insurance coverage, more than 70 sections aim to improve the healthcare delivery system itself. 2 For instance, the Center for Medicare & Medicaid Innovations was created to test innovative healthcare service and delivery mod- els that could reduce cost and pre- serve or enhance quality. 3 This article examines, from an empirical perspective, whether the health status of Americans and the quality of care they receive has improved six years after the Afford- able Care Act was enacted. Are We Healthier? The relationship between health insurance and health status is well established. In its summary of research evidence, the Institute of Medicine concluded, “Health insur- ance is integral to personal well-being and health.” 4 Approxi- health insurance they are more likely to obtain immuniza- mately 16.4 million previously uninsured people now have tions, prescription medications, asthma care and dental serv- health insurance, 5 and one can safely conclude the U.S. popu- ices. 7 Serious child health problems are identified earlier when lation, in the aggregate, is healthier. 6 children have health insurance and children are more likely to have access to specialists. 8 Evidence shows that children with Having health insurance improves the health of both adults and children. For example, when children obtain health insurance receive more timely diagnosis of serious This article was originally published in the April 2016 issue of New Jersey Lawyer, a publication of the New Jersey State Bar Association, and is reprinted here with permission. 41 N EW J ERSEY L AWYER | April 2016 NJSBA . COM
have a “usual source of care.” 25 Accord- health conditions, have fewer hospital- centage of women who had initiated izations and have better outcomes if and completed the three-dose vaccine ingly, Brown and McBride concluded, series. 17 They estimate the increase in they have asthma. 9 “the extent to which the ACA increases Adults who have health insurance are vaccine uptake equates to approximate- access and coverage, insured people with more likely to receive preventative serv- ly 1.1 million women initiating the vac- diabetes are likely to significantly ices. They are less likely to forego physi- cine and 854,000 completing the full increase their health care use, which may cian visits and delay clinically effective series. 18 lead to reduced incidence of diabetes treatments, such as taking prescription The Affordable Care Act has been complications and improved health.” 26 medication. 10 Insured adults who have credited with earlier detection in cervi- Putting the issue in its starkest terms, cancer are more likely to have it detect- cal cancer. Using a hospital-based cancer being uninsured is, quite simply, associ- ated with death. 27 In their 2009 article ed earlier. Uninsured adults with cancer, registry of 70 percent of all cancer cases cardiovascular disease, stroke, respirato- in the United States, researchers com- published in the American Journal of Pub- ry failure, COPD, asthma, hip fracture, pared two groups of women with cervi- lic Health , Andrew Wilber and others seizures and serious injury are more like- cal cancer (ages 21–25 and ages 26–34) authors (all authors at the time affiliated ly to have poorer health outcomes, lim- before and after the Affordable Care Act with Harvard Medical School) estimated went into effect. 19 They found the per- itations on quality of life and premature that approximately 45,000 deaths of death. 11 centage of women diagnosed early had Americans aged 18–64 in the year 2005 One of the more compelling studies increased for the younger group, but were associated with lack of health involves the estimated increased utiliza- remained flat in the older group. insurance. 28 tion of HPV vaccine by women between Because the Affordable Care Act allows The link between having health the ages of 19-26. 12 HPV (human papillo- dependents to continue coverage until insurance and better health is, therefore, mavirus) is “the most common sexually age 26, it impacts women in the well established, and yields a relatively transmitted infection in the United younger group but not the older group. straightforward analysis of how increas- States.” 13 The vaccine is expensive and The researchers thus concluded the ing the percentage of insureds in a pop- its high out-of-pocket cost deters utiliza- increased early diagnoses of women in ulation leads to improved health for tion. 14 the younger group were attributable to that population. The Affordable Care Act established the extended dependent coverage provi- On the other hand, the link between sion in the Affordable Care Act. 20 Earlier extended dependent coverage provi- the Affordable Care Act’s provisions sions (until age 26). 15 It also requires diagnosis of cervical cancer improves intended to improve the quality of care coverage for certain preventative health prospects for survival and improves a rendered, and assessing whether the services, including those recommended woman’s chances of preserving fertility quality actually rendered has improved, by the Advisory Committee on Immu- during treatment. 21 is less straightforward. nization Practices of the Centers for Dis- Another study looked at the effect of ease Control and Prevention. 16 One such Do the ACA Quality Incentives Work? the Affordable Care Act with respect to treatment for diabetes. 22 Derek Brown recommendation is coverage for the As noted above, the Affordable Care HPV vaccine. Accordingly, a measure- and Timothy McBride, both faculty at Act not only intends to improve access able increase in the rate of HPV vaccine Washington University’s Brown School, to healthcare services, it also intends to uptake since 2010 (when these two pro- report in their original research article improve the quality of those services. 29 visions in the Affordable Care Act went published in the May 2015 edition of Pre- By embracing concepts such as into effect) can be reasonably attributed venting Chronic Disease that diabetes was ‘value-based purchasing,’ the Affordable to the act. diagnosed in 29 million Americans in Care Act endorses models of healthcare In their study published in the May 2012, and millions of diabetics were delivery that have been implemented in uninsured. 23 Using data from the Medical 2015 edition of Health Affairs , Brandy J. various settings within the past 10 years. 30 The discussion below explores Lipton and Sandra L. Decker, both from Expenditure Panel Study Survey, they the Office of Analysis and Epidemiology, estimated that between 2011 and 2012, what has been learned about whether National Center for Health Statistics, nearly 2 million of the 13 million adults the healthcare delivery models adopted concluded the Affordable Care Act’s (aged 19–64) with diabetes were unin- by the Affordable Care Act actually sured. 24 They found those without insur- dependent coverage provisions and pre- result in improved clinical care ( i.e., ventive health provisions were indeed ance were less likely to obtain prescrip- process 31 ) and, ultimately, improved out- associated with an increase in the per- tions, make office visits to physicians and comes. 42 N EW J ERSEY L AWYER | April 2016 NJSBA . COM
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