It has survived a bitterly divided Congress and a polarized public, a narrow Supreme Court ruling, and a 16-day government shutdown triggered by an effort to defund or repeal it. Hailed by some as the most significant healthcare reform in a half-century, it is also roundly scorned by others as an ill-advised debacle.
With some of its most hotly contested provisions now taking effect, the Affordable Care Act—or Obamacare, as both backers and detractors now call it—has been the object of admiration and animosity, of optimism and consternation. Its supporters have pointed to the promise of unprecedented access to healthcare for millions, while its critics have pointed to the trickle of consumers able to access the main web portal during an error-plagued rollout.
Beyond the heated rhetoric, however, what will the complicated and quickly evolving elements of Obamacare actually mean for hospitalists and for healthcare access, affordability, capacity, and delivery? In the short term, analysts say so much change is happening all at once that it’s nearly impossible to predict how it might turn out.
“Everyone’s kind of holding their breath to see what happens,” says Ann O’Malley, MD, MPH, a senior fellow at the Washington, D.C.-based Center for Studying Health System Change.
One thing is certain: more reliance on hospital-based providers.
“I think there are a lot of things on a hospitalist’s plate right now. And hospitals, because of the cost pressures, are definitely looking to us to lead the way through this uncertain time,” says Rick Hilger, MD, SFHM, medical director for care management at Regions Hospital in St. Paul, Minn., and a hospitalist for HealthPartners.
Amid the upheaval, experts are seeing the signs of a few major trends. In the short term, one emerging theme is considerable geographical variation in consumer access and costs, and in pressure on providers.
“How this is going to feel will depend, to a great extent, on where you live,” says Leighton Ku, PhD, MPH, director of the Center for Health Policy Research at George Washington University School of Public Health and Health Services in Washington, D.C.
Analysts also have seen hints of more universal changes, including an accelerated trend toward the consolidation of provider groups, an added emphasis on team-based care, and significant momentum toward a pay-for-performance delivery model.
An Uneven Exchange
One of the law’s most visible and controversial elements, the health insurance exchange or marketplace, got off to a rocky start Oct. 1, 2013, when computer glitches hobbled the main healthcare.gov portal for 36 state exchanges and plagued many state-run sites as well.
While some state-run exchanges have generally earned high marks, others have struggled. Analysts are most worried about the balkiness of the main web-based portal, through which the majority of enrollees will have to pass. While older and sicker patients are generally more motivated to keep trying, the same isn’t necessarily true for younger and healthier people whose participation will be vital to help balance each state’s risk pool. Analysts sometimes call these people, “young invincibles.” Because they generally seek out care far less often than older consumers, their lower medical costs can help compensate for higher expenditures elsewhere.
If too few sign up, however, a state’s risk pool may be imbalanced toward costlier patients, causing insurance premiums to rise and creating a vicious cycle that destabilizes the market and makes more expensive insurance less attractive to younger people. Economists say the carrot-and-stick approach—offering subsidies to help lower-income people pay for premiums and gradually increasing financial penalties for those who choose not to buy any coverage—is likely to help. Nevertheless, supporters are nervous that malfunctioning exchange sites could cause would-be enrollees to delay or drop out, and, at the end of 2013, a worried Obama administration was scrambling to address the cascade of glitches.