PPACA Still Faces Hurdles, Academics Say

Healthcare experts from across the country say the Patient Protection and Affordable Care Act is off to a good start, but faces a rough road ahead.

A panel of distinguished academics gathered at Harvard University last week gave federally driven healthcare reform efforts high marks, but cautioned that several daunting hurdles remain.

Theda Skocpol, PhD, a Harvard professor and director of the Scholars Strategy Network, which co-sponsored the "Taking Stock of Health Reform" forum, delivered a stirring defense of the Patient Protection and Affordable Care Act.

Skocpol highlighted three areas where she believes the PPACA has made tremendous strides:

• Creating "new rules of the game" for insurance companies that improve quality of care and reduce costs;

• Boosting subsidized care through mechanisms such as Medicaid expansion to ensure health insurance coverage becomes more affordable;

• Launching exchanges that serve as marketplaces where people can compare health insurance products.

"It is surprisingly successful. It didn't look that way a year ago," she said.

Lawrence Jacobs, PhD, a political science professor at the University of Minnesota, pointed to polling data indicating that Americans are supportive of the core elements of the PPACA. They like the healthcare reform law more as they learn more about it, he added.

"The reality is, there's quite a bit of support for it," he said, citing polling data collected at Stamford University in California. "As knowledge increases, support for the Affordable Care Act rises to about 88 percent among Democrats. Even among Republicans, support rises to about 40 percent… Support for the law rises as people actually experience the benefits of the law."

In a brief interview after the forum, Jacobs noted that public support for the PPACA mirrors the historical experience with other major pieces of social legislation. "We find that the knowledge about Social Security is greatest among people who are in the program," he said.

Linda Blumberg, PhD, a senior fellow at The Urban Institute, noted that the PPACA has generated major improvements in the health insurance marketplace over a relatively short period of time.

"There has been significant reduction of the uninsured relative to the expected trend," she said, noting that millions of previously uninsured Americans have gained health insurance coverage through Medicaid expansion and the PPACA-spawned exchanges.

"We've also seen increasingly competitive insurance markets, particularly in the non-group markets… These are all very good signs."

PPACA Obstacles
The forum participants identified several impediments to the successful implementation of the PPACA, including political, financial, operational, and legal hurdles.

"The politics remain rancorous and poisonous," Skocpol said, noting that an appetite for repeal of the PPACA is "still on the table" for many of its political foes. "That reacts with a media that over-hypes the possibility of repeal."

Just two days before the Oct. 2nd forum on the Harvard campus, U.S. Rep. Kevin Brady, (R-TX), released a statement peppering the PPACA with harsh criticism.

"Today, Americans were supposed to be able to enroll in an Affordable Care Act plan for the second year, but the opening of 2015 enrollment was delayed [until] after the mid-term elections to avoid consumers finding out that much of the backend of healthcare.gov still doesn't work, and that they may face higher premiums and a more narrow network," the chairman of the House Ways and Means health subcommittee wrote on Oct. 1.

"While this poorly written law has helped some, it has hurt many, many more," Brady wrote. "One year later, too many families have had the plans they liked cancelled and can no longer see the local doctor they trusted. That is not the healthcare reform they were promised."

Skocpol places responsibility for the troubled political prospects of the PPACA squarely on the Democratic Party. It has done a poor job of explaining the law to the public, she says. "Most Americans still don't know what is in this law; so it's wrong to conclude that if they did know, they wouldn't like it."

Blumberg said the prevalence of cost sharing seen as high-deductible health plans on the new exchanges has emerged as a key financial stumbling block to offering affordable healthcare coverage to all Americans. "The cost sharing can be very high relative to their income," she said.

Katherine Swartz, PhD, a professor of health policy and economics at Harvard, said the PPACA stopped insurance carriers from denying coverage due to pre-existing conditions, but she noted that risk selection remains a threat to healthcare access.

Carriers have cast a wary eye on the least profitable markets and public exchanges and "they could stay out of certain marketplaces," Swartz said.

Narrow Networks
In response to a question from the forum's audience of about 75 people, Blumberg said "price gouging" of patients who seek medical care outside of narrow networks is a concern in many states. "We're at the beginning of what is going to be a very tension-filled conversation," she said of the simmering debate over network adequacy.

Blumberg said operational problems, such as last fall's nearly disastrous rollout of healthcare.gov, are likely to be a perennial. "What we had before was a very patchwork kind of system," Now, she said, "You've got more patches on the patches."

She believes the struggle to optimize healthcare.gov reflects the PPACA's byzantine set of regulations. "The policy we have created has complex operational needs," she said. "What we don't recognize is that it's the policy that drives the complexity of this system."

Timothy Jost, JD, a professor of law at Washington and Lee University in Virginia, said court challenges seeking to eliminate health coverage subsidies in federally administered insurance exchanges could have disastrous consequences for the PPACA. If those challenges reach the U.S. Supreme Court and are successful, he said, they "will not only gut the federal exchanges but also gut the non-group market."

"I don't think the judges really understand that," Jost said.

Educating the public

One of the most challenging obstacles to effective implementation of the PPACA is the woeful status of healthcare literacy among Americans, several forum participants argued.

"We have a conglomeration of media and political parties that make fact-based evaluation [of healthcare by] regular citizens all but impossible," Jacobs said, noting the shift from the "Cronkite era" when there were limited sources of information on public policy to the prevalence of media outlets today that package news to fit viewers' preconceived notions. "There's a business and political reward to feeding that hunger."

Jonathan Gruber, PhD, a professor of economics at the Massachusetts Institute of Technology in Cambridge, and an architect of the healthcare reform law, stressed the need "to try lots of different mediums" to improve healthcare literacy.

"It's not a lack of material. It's a lack of getting people to be interested in it," he said of matching the vast amount healthcare reform information linked to the PPACA with individual members of the public.

Blumberg suggested that the need for healthcare literacy education is greatest among Americans who were previously uninsured and are now shopping for insurance coverage on the new public exchanges. "When you look at the specific target population in the exchanges… about half of them don't know what a premium is," she said. "What we need is a lot more hand-holding."