Americans are watching and waiting — with anxiety, skepticism, optimism and sometimes all of the above — to see what becomes of the Affordable Care Act, the mammoth health law that added 18-million people to the ranks of the insured.
And even expert economists and physicians who have spent decades analyzing the complex system can't say with any certainty what could happen next. But watching the politics of "repeal and replace" can be just as painful for those in the know, said a panel of high-powered health policy authorities who gathered Thursday evening at the Inquirer to ponder the possibilities.
“I’m talking back to the TV again whenever something comes on about health care,” said Mark Pauly, professor in the Department of Health Care Management at Wharton who has studied the health system for half a century.
Panelists agreed on three points:
Understanding insurance is really hard, even for experts.
Significant parts of the Affordable Care Act will be dismantled, but some protections will remain.
As long as American health care continues to be driven by cutting-edge technology and expensive new drugs, no one should expect costs to decline.
Much attention has been paid to a Congressional Budget Office finding that 18-million Americans who get insurance through the ACA marketplace exchanges could lose their plans if Obamacare is repealed. That's a big-sounding number, but “a fraction of the total population,” said Pauly. “If you’re an average American you don’t really have a big dog in the fight.”
Yet the ACA reaches into the health insurance lives of many more people than that.
Physician David Grande said what worries him most about the incoming administration is what could happen to Medicaid, which provides coverage for low-income Americans and was expanded considerably through Obamacare.
Medicaid “is certainly in the crosshairs,” said Grande, assistant professor of medicine at the University of Pennsylvania School of Medicine. “And it gets lost in the shuffle of public debate.”
Though President Trump and Republican leaders in Congress have promised to repeal Obamacare and replace it with something better, no single plan has emerged.
Under one scheme, dubbed A Better Way, the states would have a much greater role in determining minimum coverage rules, which proponents hope will lead to less expensive and more streamlined benefit programs, said Scott Harrington, chairman of the Health Care Management department at Wharton.
“The details are vague,” Harrington said. “But that’s one of the concepts underlying the proposal.”
Changes to any plan for coverage comes with some risk, said Robert Field, editor of Philly.com's Health Cents blog and professor of health management and policy at Drexel University. Still, it can be done.
“Addressing health care is not like touching the third rail,” Field said. “It’s more like sticking a fork in a toaster. You can get your toast out, but you have to be really careful. People have long memories.”
Richard Snyder, chief medical officer for Independence Blue Cross, stressed that losing key provisions of the ACA could have catastrophic results. As it works now, children up to the age of 26 are covered under their parents' insurance, and the ACA also has expanded access to mental health care. As the opioid epidemic rages, the ACA has allowed more young adults to seek addiction services.
“We have seen almost a doubling of the cost and utilization of substance abuse treatment,” Snyder said. “We know we have a massive problem in this city.”
Nearly 900 people died of drug overdoses in Philadelphia in 2016, triple the number of homicides.
“I don’t know how bad it would have been in people didn’t have access to care,” said Snyder, who is a physician. “It could have been worse.”
The ACA also has programs aimed at improving the quality of medical care, but this has seen limited success in the region, he said.
“We have very, very high costs and very, very high utilization in Philadelphia,” Snyder said. But despite the city's numerous teaching hospitals, “we only have average quality in aggregate.”