The Affordable Care Act and the Missing Accountability

The Affordable Care Act added new accountabilities for many players within the health care system.  This includes Accountable Care Organizations (ACOs), hospital systems, health insurance providers, state medicaid agencies, and others.  The one accountability that appears to be missing is that related to the patient or individual.

Many years ago, when taking one of my children to their health care provider, I noticed a sign that stated simply, "There is nothing that the doctor can do to make up for what the patient will not do."

Most of us in health care have found this to be true.  If the physician diagnoses a condition and prescribes a medication, that medication does not work unless the patient gets the prescription filled and takes it appropriately.  Many other examples exist, including patient exercise, appropriate diet, etc.  For health care delivery to be effective, the patient needs to be involved and accept accountability for their behavior and its impact on their health.

Many employers and health insurance providers have been working to increase patient or individual accountability.  Many techniques have been or are being used, including copayment reductions, premium adjustments, and others.  When used appropriately, methods to increase patient or individual accountability have been shown to improve the involvement of the individual and the subsequent health outcome.

However, in the Affordable Care Act, patient or individual accountability was forgotten or neglected.  Instead, the bill was written to decrease the accountability of the individual.  If the individual does not want to pay a full premium, they can wait until they need care and then pay a small penalty.  If the patient wants preventive care, they do not need to decide if it is appropriate for them and efffective for their specific case, they can get this care at no cost.  If a patient is seeing a physician in an ACO, but does not want to follow their recommendations, they can see a physician outside that ACO, and the physician now bears financial risk, not the patient.

I hope that as future legislation and regulations are considered that some focus will be on increasing the accountability of the individual, thus encouraging them to be a more active participant in their health delivery and the subsequent outcomes.

Supreme Court Hearings on the Affordable Care Act

Here is this week’s agenda for the Supreme Court hearings:

Monday - 90 minutes on the Anti-Injunction Act – The Court will be reviewing whether or not courts have jurisdiction to decide the case now, or do they need to wait until a person faced with the individual mandate pays the penalty, which could be considered a tax.  If they decide they do not have jurisdiction until someone pays the penalty, the case could be delayed until April 2015.

Tuesday – 120 minutes on the individual mandate – The Court will look at whether or not it is constitutional for Congress to require people to buy health insurance.  The white house argues that it is constitutional as a form of regulating interstate commerce.  This is the main issue in the case, and one which has received different opinions in lower courts.  The mandate becomes effective in 2014.

Wednesday - 90 minutes on severability – The issue is whether or not the rest of the law stands if the individual mandate is ruled unconstitutional.  The Affordable Care Act did not include a clause stating that if any portion of the law is deemed unconstitutional, the remaining components remain intact.

Wednesday – 60 minutes on Medicaid expansion – States challenging the law have said it is coercive, conditioning future federal funding on states’ participation in the expanded Medicaid.

It is probable that the Supreme Court will provide their responses to these issues in late June of this year.

On the Anniversary of The Affordable Care Act - A Look At The Individual Mandate and Pre-Existing Conditions

Today, March 23rd, is the 2nd anniversary of the Affordable Care Act.  As the Supreme Court begins hearings next week on the constitutionality of the individual mandate, it is important to remember how the individual mandate is linked to how the law deals with pre-existing conditions.

Under the Affordable Care Act, starting in 2014, Americans with pre-existing conditions cannot be denied coverage or be charged significantly higher premiums.  In the past, when some states passed laws requiring insurance companies to accept new members with pre-existing conditions, most insurance companies either stopped offering benefits to individuals or lost millions of dollars.  This is because many healthy individuals did not get coverage, unless they became ill.  When healthy individuals do not get coverage and do not pay premiums, the money is not there to pay the costs for those individuals that are not healthy.

What it comes down to, is that if the individual mandate is removed from the Affordable Care Act, and insurance companies must still accept individual members with pre-existing conditions, it could lead to a situation where insurance companies can only afford to offer coverage though employer groups and not offer coverage to individuals that seek health insurance coverage on their own.

It will be interesting to watch what happens with the pre-existing condition components of the law if the Supreme Court declares the individual mandate unconstitutional but leaves the rest of the law intact.