Thursday, March 13, 2014

What I Learned About The ACA

One of the big draws for me at the Workers' Compensation Research Institute's annual meeting this year was to hear from one of the architects and authors of the Affordable Care Act, Dr. Jonathan Gruber who is a professor of economics at Massachusetts Institute of Technology.

I just needed to learn. The ACA is so complex, so huge, so broad in its scope, that anyone who is not completely versed in the health care system (the vast majority of us) would have absolutely no understanding of the law, how it plays out, who it really affects, what is to come of various provisions, etc.

In fact, I am willing to bet that virtually all lawmakers, including our president himself, have little to no true understanding of the law.

Dr. Gruber is a health economics expert - meaning he has spent virtually all of his professional life studying health care systems and the economic underpinnings of health care.

It is enormously complex because there are so many moving parts, so much is tied into human characteristics and psychology, and as a consequence there are many different unintended consequences that are just going to have to play out.

And the main point I took away from Dr. Gruber's presentation is ... unfortunately ... we are going to have to wait and see how everything plays out.

Dr. Gruber explained that the model for the ACA was then Massachusetts' Gov. Mitt Romney's health care reform. That reform took at least 3 years for it to mature and for people to understand the impact.

Dr. Gruber said the lessons learned from Romney Care (fair enough?) is that reform is a three legged stool and without all three legs the stool falls over:

1. There can not be discrimination against pre-existing or co-morbid conditions. This is what is know in the health insurance industry as "community rating" - i.e. everyone is covered regardless of current or known health conditions that may affect actuarial partiality.

2. As many people as possible need to participate, thus there must be some form of individual mandate - the population that is without health insurance is either young and healthy and not inclined to spend for insurance or is poor and unhealthy and can't afford insurance, which is why:

3. There must be some form of government subsidy for the people that are uninsured and can not feasibly participate on a financial level otherwise the second leg, individual mandate, fails.

According to Dr. Garber the results in Massachusetts was that the population went from 18% uninsured to just 3%.

But this model can not be scaled to a national level because there was one big political factor that made the state a success where others would fail - the state had "ripped off" (Dr. Gruber's description, not mine) Medicaid of $500 million and Romney went to President Bush at the time to get a concession of forgiveness in repayment if that money was used to finance the uninsured.

No other state had, or has, that luxury.

So the big question is, of course, to us in the work comp industry is what does the ACA mean to work comp?

Coincidentally The National Law Review published an article yesterday by Mark Walls that was originally published in Risk Management magazine (thanks for bringing this to my attention Jon Gelman!) that predicts that the ACA won't affect overall health of Americans (i.e. no evidence that we will have healthier workers and, ergo, fewer claims), that there will be no reduction in cost shifting and that in fact it may increase against work comp, that access to care is a real problem because there aren't enough doctors around to pick up the extra capacity, and that standards of care may actually improve.

(I'm sure Mark will correct me if I have the conclusions incorrect.)

Some of the elements Mark talks about in his article were addressed by Dr. Gruber.

For instance Dr. Gruber said that based on Massachusetts experience the access to care will not be significantly impacted. He noted that the state had in general a 47 day wait for doctor access before reform and 51 days after. Indeed, I tend to believe that the market for physicians will correct any access issues - that any shortage of American born physicians coming out of medical school will be corrected by physicians trained in other lands, and indeed we have been seeing that trend in the past few years regardless of the ACA. After all, America is the land of opportunity and immigration has always fulfilled labor supply shortages.

I agree with Mark that there won't be any change in cost shifting - there are too many variables in the way that mess with motivations and other elements that may cause one person to seek general health care or work comp care, and those variables are shared between employers, workers, physicians, and insurance companies themselves.

In fact Dr. Gruber said that the challenge with work comp to avoid cost shifting is that work comp pays better - but he doesn't understand completely that work comp also involves a much heavier paper element and pays later in general too - such that in my experience most physicians say they avoid work comp except those who have specialized in occupational medicine.

There were two immutable points that Dr. Gruber made however that will hugely impact the health care versus workers' compensation interaction as this all plays out over the next few years:

1) The vast majority of American health care consumers pay way too little attention to their health care decisions and availability of choices (indeed, workers' compensation has the lowest barrier of entry to medical care with no co-pay and the cost of the insurance hidden in the pricing of products or services produced by the employer); and

2) Politics can screw everything up regardless of who's right, who's wrong or whatever the issue is.

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