Fact Check: the Colorado Case for Repeal of the Affordable Care Act (and replacement with the Affordable Health Care Act) is a False Narrative

The Affordable Health Care Act (AHCA or “Trumpcare”) will cut 24 million from insurance by 2026 including 410,600 from Colorado (use this interactive feature to see how many will be impacted in your state).  Colorado’s own Senator Cory Gardner has expressed his reservations about the 14 million projected to lose Medicaid, describing Medicaid as providing “access to life-saving health care services” for the 1.3 million Coloradans—and 72 million Americans—who get their insurance through Medicaid, including the Medicaid expansion part of the Affordable Care Act (ACA). Given the ominous projections about the AHCA’s impact compared to staying with the ACA, how did Republican legislators end up with such a destructive bill after 8 years of decrying the disastrous results of the ACA? The unfortunate reality of what the ACA-to-AHCA transition would mean highlights the accomplishments of the ACA as it is on the verge of elimination: it has improved healthcare access and outcomes for millions of Americans.

The mythology on which the Republican members of congress have based their anti-ACA rhetoric is exemplified by the talking points used by our Colorado legislators. Senator Gardner has reiterated his anti-ACA talking points in his two recent tele-town halls.   As he has before, Senator Gardner gave three arguments for why the ACA must be repealed:

  • Health insurance premiums in Colorado are rising because of the ACA
  • Coloradans lost their health insurance because of the ACA
  • Coloradans can’t access their doctor because of the ACA

Each argument bent the truth, casting the ACA as causing the problem rather than what the data shows it is: part of the solution. If the ACA did not cause the problem, repeal is not the solution.

  • Premiums are rising.  True, but we don’t know how much is due to the ACA and the rise is exaggerated. Premiums were rising before the ACA. This year’s rise brought lower-than-predicted premiums into line with the 2017 rates predicted by the CBO in 2009. The 400% rise cited by Senator Gardner in both tele town halls– of “people whose premium rose from $300 to $1500 a month”—grossly overstates the average rise of 20.4% in Colorado–an increase that primarily impacts those who buy individual policies—about 3% of the population–and is often offset by subsidies.
  • Hundreds of thousands of Coloradans lost insurance: Not true.   By “lost insurance”, the Senator is referring to “churn”—transitioning between plans, sometimes a result of canceled plans—and not about a net loss in insured people in Colorado. The rate of churn was not increased by the ACA. Most cancelations—about 250,000—involved limited benefit plans that were not ACA-compliant, and thus had to be either made ACA-compliant or dropped when the ACA was enacted.  Despite the churn, Colorado has nevertheless seen a net increase of over 530,000 in the number insured. In fact, Coloradans continue to enroll in plans in record-breaking numbers, with a 12% increase seen over the same time last year in the 2017 open enrollment period.
  • People can’t see their doctors because of high deductibles. Not true.  The 2015 Colorado Health Access Survey shows that, since the ACA was passed, increased coverage has meant increased access. Coloradans have steadily increased their rate of preventive health visits by 7% (from 61.9% in 2013 to 66.1% in 2015) and have lowered their rate of skipping doctors’ visits due to costs by 15% (from 12.3% in 2013 to 10.4% in 2015).

Although rising premiums, churn and barriers to accessing doctors were not eradicated by the ACA, this review of Colorado data shows that the ACA is part of the solution, not part of the problem. To do what is best for Coloradans, Senator Gardner needs to step away from his false narrative about the ACA and address real issues reflected in Colorado data.  He has taken a first step in raising concerns about threats to Medicaid. There are ways to strengthen the ACA to address some of the real issues in healthcare, but to repeal it based on a false narrative disseminated by Senator Gardner and his Republican colleagues would be a tragedy.  Let’s look at the facts, and work together to make the system better, for Colorado and the rest of America.

 

 

CBO report on the AHCA: 24 million will lose coverage

The nonpartisan Congressional Budget Office has released their report on the GOP’s Affordable Care Act (ACA) replacement plan. The numbers released in this report are grim, and will only make it more difficult for Republicans to explain why their legislation will outperform the ACA.The bottom line is that 14 million will lose coverage under this plan in 2018, rising to 21 million in 2020 and 24 million in 2026. In the non group market, premiums will rise 15-20% in 2018 and 2019.

The Affordable Care Act is Good for Colorado (and Repeal is Not)

The effects of the Affordable Care Act of 2010 in each state depend on various factors, such as the number of uninsured individuals in the state and the governor’s receptiveness to the law’s provisions. In this post, I focus on the benefits of the Affordable Care Act (ACA) in Colorado, primarily from the perspective of my job as an emergency department (ED) physician, in support of my argument that the ACA must not be repealed–instead, I recommend that it be strengthened. In a prior post, I summarized estimates of the impact of the GOP’s proposed ACA repeal/replace plans on coverage and consumer costs.

Effects of the ACA on Uninsurance Rate in Colorado

In Colorado, the number of uninsured individuals declined by 25.5%, from 729,000 individuals in 2013, or 14.1% of the population, to 543,000 individuals in 2014, or 10.3% of the population. colorado-uninsurance-rate

Colorado was one of 32 states (including DC) that had expanded Medicaid as of 1/1/2017. In fiscal year 2014, annual Medicaid enrollment in Colorado increased by 26.1%. Average monthly enrollment increased 59% from 783,420 to 1,244,031 pre-ACA to post-ACA.

Drivers of Healthcare Cost and Utilization from the Emergency Department Perspective

Healthcare access and coverage–so improved under the ACA–drive a lot of what happens in the emergency department (ED). We can think of this in 3 categories:

  1. How the ACA has impacted who comes into the ED (and the hospital).
  2. How the ACA has decreased the amount of services we ED physicians provide to patients while they are in the ED (and hence the cost).
  3. How the ACA has impacted what happens at the end of the ED visit (should I stay or should I go?)

drivers-of-ed-utilization

How the ACA has impacted who comes into the ED (and the hospital)

In Colorado, the number of ED visits has declined with ACA implementation. This varies state, by state, but in Colorado, we have seen a clear decline in the rate of ED visits per insured person–a trend driven by the expansion of Medicaid insurance.

decline-ed-visits-all-ages-co

The trend is also apparent when we restrict the analysis to children only:decline-ed-visits-children-co

(This and other data are available from the Colorado All Payer Claims Data summary tools, at Colorado Medical Price Compare, available at https://www.comedprice.org/#/reports )

The decline in population rate of ED visits among Medicaid patients did not result in a net decline in the number of ED visits–in 2014, the overall number of Medicaid ED visits went up, largely because more patients were on Medicaid. But, among those on Medicaid, during the ACA rollout, population rates of ED visits went down. As expected, the number of un-insured ED visits declined in Colorado as the number of Medicaid visits rose.

medicaid_ed_100814-01

Increasingly, patients are more likely to visit their medical home (primary care provider) because they are more likely to have one, thanks to the ACA.  When we do see patients in the ED, patients are more likely to have had started treatment before coming in (saw or called their medical home). Diverting more ED visits to the medical home is good for many reasons, not the least of which is cost. cost-ed-vs-pcp

The decline in ED visits is also a Colorado Medicaid performance metric for Colorado’s seven Regional Care Collaborative Organizations (RCCOs)–RCCOs received payment incentives if they achieved a 3% decline in ED visits per patient in their RCCO. Although most RCCOs did not achieve this decline, all achieved some decline in 2016:rcco-level-ed-visit-reduction-medicaid

How the ACA has decreased the amount of services we ED physicians provide to patients while they are in the ED (and hence the cost)

If we know a patient in the ED has no coverage (no financial access to primary care), the ED visit costs more for many reasons, including:

  • The patient is more likely to have tests done in the ED because there is no primary care provider to order tests and follow test results
  • The patient is more likely to have subspecialty consultations instead of office follow-up visits with primary care providers
  • The patient is more likely to get more conservative (more aggressive) treatment in the ED, rather than waiting a day or two to see if the patient really needs more aggressive testing/treatment, because there is no medical home to provide that testing/treatment in a day or two.

 

How the ACA has impacted what happens at the end of the ED visit

If we, as ED physicians, know a patient has financial access to primary care, we are more likely to discharge them home rather than admit them to the hospital. This is reflected in the decrease in hospital admissions relative to the rate of ED visits among all ages:

decline-ed-admit-rate-all-ages-co

The same trend is seen among children only:decline-ed-admit-rate-children-co

As an example of how this works, one of the most common reasons young children are admitted to the hospital in Colorado (and nationwide) is for a common lower respiratory viral syndrome called bronchiolitis. Several of my colleagues at Children’s Hospital of Colorado have performed the research (here and here) to show the circumstances under which a child is safely discharged home on home-oxygen therapy. This is cost-saving in that hospitalizations are expensive, and also result in many missed days of work for parents. The criteria for discharge to home (rather than hospital admission) in our hospital’s evidence based guideline include access (within 24 hours) to a medical home for a follow up check:

bronchiolitis-home-oxygen-ccg

Before the ACA permitted so many more access to a medical home, patients with common conditions like bronchiolitis were more likely to be admitted. Discharging more to home means fewer inpatient stays:

decline-ip-visits-all-ages-codecline-ip-visits-children-co

Thus, for Colorado consumers, the ACA has helped improve coverage, thereby reducing the per-insured rate of ED visits, the per-ED-visit rate of inpatient admissions and the overall rate of inpatient admissions, both for adults and children. It has primarily done this by allowing more Coloradans to access care where they should be able to: in a medical home. By reducing these costly forms of healthcare utilization, EDs are less crowded for those who truly need ED care. By reducing the proportion of uninsured visitors to the ED and hospital, the ACA has also decreased the amount of uncompensated care, permitting more hospitals to remain in business.

What Happened to Jeffrey Beall’s List of (Allegedly) Predatory Publishers?

Jeffrey Beall is an academic librarian at the Auraria Library at University of Colorado Denver located in Denver, Colorado. He got tenure in 2012 and became an associate professor. For a number of …

Source: What Happened to Jeffrey Beall’s List of (Allegedly) Predatory Publishers?