Far from being the last word on health reform, the passage of the Affordable Care Act has become the catalyst for a wave of innovation and experimentation at the state level, according to a University of Minnesota political scientist who spoke in Albuquerque.
“We’re in a new era,” said Lawrence R. Jacobs of the Center for the Study of Politics and Governance, who spoke at the University of New Mexico under the auspices of the Scholars Strategy Network and UNM’s Center for Health Policy earlier this month.
The ACA, also known as Obamacare, has created a framework, incentives and mechanisms that encourage state experiments in health reform, Jacobs said.
That’s a good thing, too, since congressional gridlock around the issue is likely to continue, he said.
“There will be no sensible conversation in Washington on health reform for many years,” Jacobs said.
A provision of the ACA that provides federal funds to extend Medicaid benefits to an estimated 16 million working-poor adults has set off a flurry of experiments in the states, he said.
All states led by Democrats accepted federal funds and expanded Medicaid, at least partly for humanitarian reasons. Over time, millions of preventable deaths will be avoided because states offer Medicaid to the working poor, Jacobs said.
Republican governors largely opposed the expansion at first. By last year, however, states as conservative as Arizona and Utah began accepting federal Medicaid expansion dollars in response to pressure from hospital executives and business leaders who felt their states could use the money, Jacobs said. (New Mexico Republican Gov. Susana Martinez accepted the Medicaid money early on.)
The federal government always has paid the lion’s share of Medicaid, but the program’s administration is left to the states. Uncle Sam has long encouraged states to find new and better ways to deliver care, and they are.
Vermont is developing a plan to establish a state-level, single-payer, health-care financing system. Wisconsin, which rejected new Medicaid money, is still trying to sign up more state residents for a “more restrictive” Medicaid plan, Jacobs said.
Texas, which also rejected Medicaid expansion, is among 45 states using federal funds to update Medicaid information technology and administrative systems, which has led to new enrollment of eligible residents into existing state Medicaid programs, he said.
The federal government has approved plans to use Medicaid funds to subsidize private businesses or insurance plans in Arkansas, Iowa and Wisconsin.
During the debate over the ACA, progressives unsuccessfully pushed what they called a public option, which would have established a government-run insurance operation to compete with private insurers. Now some states are teaming up to create regional public options to be sold on insurance exchanges, Jacobs said.
Insurers and state health programs have been looking for ways to control costs for some time. ACA has given new support to such efforts through incentives to pay for quality of care instead of quantity of care and to reduce hospital readmissions, he said.
The ACA is designed to make certain nearly everyone in the country has the same coverage, by requiring people to have insurance, by setting minimum standards for coverage, and by forbidding insurers to deny or limit coverage.
The result, Jacobs said, is that debates over health policy can move on to issues other than how to cover tens of millions of uninsured Americans, issues such as geographic disparities in care, new ways to deliver and pay for care, race and poverty.
The nation for years has had huge disparities in health care among populations. Low-income, less-educated and some minority populations have measurably worse health than other populations. Eliminating the lack of coverage as a cause of disparities will allow for a better debate that can focus on factors such as lifestyles, culture, discrimination and other factors, Jacobs said.
The act has encouraged development of health insurance cooperatives. Jacobs expects Indian tribes and credit unions to start forming cooperatives to finance health care.