By Ned Calonge, MD, MPH
With the Supreme Court decision on the Affordable Care Act (ACA) due in days, it’s worth looking at how well the law has worked since it was passed.
In Colorado, the ACA is doing much of what it was supposed to do. It has vastly expanded insurance coverage in the state. While there is still a great deal of work needed to lower health care costs and improve access and quality, several initiatives are taking our system of care in the right direction.
In 2013, before the full impact of ACA implementation, an estimated 741,000 of the 3.3 million Coloradans lacked health insurance. Statistics released in March 2015 indicate that 140,000 Coloradans have signed up for insurance through Connect for Health Colorado, our state exchange. Fifty-four percent of these individuals have federal subsidies for their insurance.
Since 2013, 449,000 Coloradans have signed up for Medicaid or the Children’s Health Insurance Program, according to federal data. The 2015 iteration of the Trust-sponsored Colorado Health Access Survey (CHAS), which should be released this fall, will provide a new estimate of how these enrollment increases has changed Colorado’s total uninsurance rate. Meanwhile, estimates from Be Healthy Denver are that in Denver County, more than 94 percent of residents now have health insurance, compared with 84 percent before the ACA.
The health effects of being uninsured are well documented. Many Coloradans without insurance report that they delay filling prescriptions or avoid seeking doctor’s appointments because of cost concerns, according to the 2013 CHAS. And delaying or avoiding needed medical care can put lives at risk.
The expansion of insurance doesn’t mean perfect access to care has been achieved. Increasing coverage is only one part of getting needed health care; people also need to be able to afford their payments and to get appointments with doctors and other health care providers when they need them.
Health care reform has fallen short of its potential in some of these areas. The ACA offers no requirements that providers change their care delivery and payment systems to decrease cost and increase value. Needlessly high-cost drugs and services aren’t directly addressed. And the penalties on businesses and individuals who don’t comply with the law are still too low to make it as effective as it could be; cost savings depend on healthy young people buying insurance to dilute financial risk to payers.
At the same time, too many people are still uninsured, including undocumented immigrants who were left out of health care reform completely.
Several promising initiatives in the state could work to decrease health care costs and improve quality.
Seven Regional Care Collaborative Organizations were established throughout the state to develop a network of providers, support them with coaching and information, and manage and coordinate the care of their members. Providers contract with these accountable-care collaboratives to serve as primary-care medical homes for their members, while a contractor collects data to analyze how members are using health care services. Using performance indicators like emergency room visits and 30-day hospital readmissions, the regional collaboratives and the medical homes are assessed and rewarded for reaching key targets.
Another program, the state’s Comprehensive Primary Care Initiative, offers primary care practices incentives to coordinate care, and to improve access and continuity. Along with moving toward higher-quality care and lower costs, the results of this effort will inform future Medicare and Medicaid policy.
A third effort, supported by a $65 million State Innovation Model grant from the federal government, will support the integration of physical and behavioral health care through outcome-based payments. This initiative will build on other state programs aimed at improving transparency and rewarding high-quality coordinated care.
These gains are fragile. They are at risk if the Supreme Court strikes down the ACA provision it is now considering. Colorado’s state-run exchange may insulate it temporarily from the immediate impact of a ruling for plaintiffs in King v. Burwell—yet future legislative and regulatory actions in response to such a verdict would inevitably affect all newly covered Americans, including Coloradans. Indeed, this isn’t merely an academic question. The health of thousands of Americans may depend on the justices’ decision.