historic pieces of legislation, benefiting the most vulner- able members of our society. ... the financial sting of high
Editor’s Perspective Repealing the Affordable Care Act America’s Moral Test William B. Borden, MD; Brahmajee K. Nallamothu, MD, MPH This period of stalemate is about to change. With the new Congress and incoming administration now rapidly moving to make good on years of promises to repeal the ACA, though without any clear replacement plan, potential catastrophe looms. In the new administration’s first executive order, federal agencies have been directed to limit the economic and regulatory burden of the ACA, while plans for full repeal loom. Beyond its symbolic significance, what this executive order actually implies is unknown. Reports are already buzzing about potential Medicare expansion, Medicaid block grants, and the re-establishment of high-risk pools but without specific details. The prospect of repeal without adequate replacement will pull insurance coverage away from families, erase protections such as preventing insurers from discriminating based on preexisting conditions, and send healthcare marketplaces into chaos. These effects will have real and painful consequences for millions. Much has been written in recent weeks and months about the impact of repeal. However, as Editors of CQO, we feel that repealing the ACA has specific risks to cardiovascular health that warrant highlighting. Let’s be clear: gaining health insurance has been associated with lower overall mortality; improvements in myocardial infarction, severe angina, and heart failure hospitalization rates; better access to care; and greater self-reported health, including among individuals with cardiovascular disease or its risk factors such as diabetes mellitus.4,5 Lack of insurance is linked to a lower likelihood of receiving evidence-based care for coronary disease and advanced technologies such as drug-eluting stents,6,7 delays in treatment for myocardial infarction,8 and more cardiovascular events after percutaneous coronary intervention.9 Studies of individuals who had health insurance and then lost it, as may happen if the ACA repeal occurs, show declines in blood pressure control and rises in hemoglobin A1c.10,11 Indeed, Tumin et al12 just demonstrated the importance of insurance trajectories on long-term survival after cardiac transplant in the pages of CQO this past year. Evidence linking health insurance coverage and improved cardiovascular health therefore is strong, and evidence showing the ACA has improved health insurance coverage also is strong. These gains should not be taken lightly. We readily acknowledge that modifications and improvements to the ACA are necessary both to extend access even further and to better curb healthcare costs. Although we would argue that incremental change would be preferable to repeal, this seems unlikely at this time. Therefore, we would hope that if Congress and the new administration move forward with repealing the ACA, they do it only when they have a better plan in place that avoids unnecessary shocks to healthcare markets and ensures continuous and sufficient coverage for our patients. If no better plan is available, then we hope that they will take the
The moral test of government is how it treats those who are in the dawn of life, the children; those who are in the twilight of life, the aged; and those in the shadows of life, the sick, the needy and the handicapped. —Hubert H. Humphrey
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T
he Affordable Care Act (ACA) is one of America’s most historic pieces of legislation, benefiting the most vulnerable members of our society. The facts stand that the ACA brought health insurance to 20 million more Americans and improved coverage for everyone by requiring that plans include certain fundamental healthcare services, such as preventive and mental health care.1 Although Americans still feel the financial sting of high overall healthcare costs, the ACA kept average premium increases from growing, breaking from the dramatic upward trend of the early 2000s.2 Moreover, the ACA took a large step forward in moving our health system from rewarding volume to rewarding value—a topic that Circulation: Cardiovascular Quality and Outcomes (CQO) will focus on in the next several years.3 By all these measures, the law represents substantial progress in the health of our country. Is the ACA perfect? No. Since its passage, reasonable concerns have been raised about the law’s complexity and implementation. Specifics on the establishment of health insurance exchanges, employers’ responsibilities for cost coverage, and the individual mandate have plagued the ACA from the beginning, as well as its inability to address key issues such as tort reform and rising drug costs. But rather than address these concerns and focus on the law’s improvements, the Obama administration and previous Congresses have largely spent the past several years battling over legal challenges and vain attempts at large-scale repeal. This uncertainty has frozen progress on many fronts, and Americans have largely suffered. The opinions expressed in this article are not necessarily those of the authors’ employers, grant funding agencies, or the American Heart Association. From the Department of Medicine, George Washington University, DC (W.B.B.); VA Health Services Research and Development Center for Clinical Management Research, VA Ann Arbor Healthcare System, MI (B.K.N.); and Department of Internal Medicine, Michigan Center for Health Analytics and Medical Prediction (M-CHAMP), University of Michigan Medical School, Ann Arbor (B.K.N.). Correspondence to Department of Medicine, George Washington University, 2150 Pennsylvania Ave NW, 10-414 Washington, DC 20037. E-mail
[email protected] (Circ Cardiovasc Qual Outcomes. 2017;10:e003598. DOI: 10.1161/CIRCOUTCOMES.117.003598.) © 2017 American Heart Association, Inc. Circ Cardiovasc Qual Outcomes is available at http://circoutcomes.ahajournals.org DOI: 10.1161/CIRCOUTCOMES.117.003598
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2 Borden and Nallamothu ACA and Health Care Policy courageous act to keep the ACA and work to improve it. The cardiovascular health of Americans depends on it. For our part, we promise as Editors of CQO to continue to seek out and publish important pieces that we hope will inform and influence these looming debates in the coming years. To the cardiovascular community, we ask that we all continue providing the highest quality, most appropriate care possible, and finding ways that we can help to ensure that all of our patients have sufficient access to care. And finally, we ask our community to use our voices to hold our government officials accountable to meeting America’s moral test of caring for those vulnerable individuals in the dawn, twilight, and shadows of life.
Disclosures Downloaded from http://circoutcomes.ahajournals.org/ by guest on October 4, 2017
Dr Borden consults for the Agency for Healthcare Research and Quality, and Dr Nallamothu reports prior work on the Scientific Cardiac Advisory Board for United Healthcare.
References 1. Obama B. United States Health Care Reform: progress to date and next steps. JAMA. 2016;316:525–532. doi: 10.1001/jama.2016.9797. 2. Claxton G, Rae M, Long M, Panchal N, Damico A, Kenward K, Whitmore H. Employer Health Benefits: 2015 Annual Survey. Kaiser Family Foundation. http://files.kff.org/attachment/report-2015-employer-healthbenefits-survey. Accessed January 23, 2017. 3. Ho PM. Evaluating value series. Circ Cardiovasc Qual Outcomes. 2017;10:e003153. doi: 10.1161/CIRCOUTCOMES.116.003513.
4. McWilliams JM, Meara E, Zaslavsky AM, Ayanian JZ. Health of previously uninsured adults after acquiring Medicare coverage. JAMA. 2007;298:2886–2894. doi: 10.1001/jama.298.24.2886. 5. Sommers BD, Baicker K, Epstein AM. Mortality and access to care among adults after state Medicaid expansions. N Engl J Med. 2012;367:1025– 1034. doi: 10.1056/NEJMsa1202099. 6. Smolderen KG, Spertus JA, Tang F, Oetgen W, Borden WB, Ting HH, Chan PS. Treatment differences by health insurance among outpatients with coronary artery disease: insights from the national cardiovascular data registry. J Am Coll Cardiol. 2013;61:1069–1075. doi: 10.1016/j. jacc.2012.11.058. 7. Kao J, Vicuna R, House JA, Rumsfeld JS, Ting HH, Spertus JA. Disparity in drug-eluting stent utilization by insurance type. Am Heart J. 2008;156:1133–1140. doi: 10.1016/j.ahj.2008.07.012. 8. Smolderen KG, Spertus JA, Nallamothu BK, Krumholz HM, Tang F, Ross JS, Ting HH, Alexander KP, Rathore SS, Chan PS. Health care insurance, financial concerns in accessing care, and delays to hospital presentation in acute myocardial infarction. JAMA. 2010;303:1392–1400. doi: 10.1001/ jama.2010.409. 9. Gaglia MA Jr, Torguson R, Xue Z, Gonzalez MA, Ben-Dor I, Maluenda G, Mahmoudi M, Sardi G, Wakabayashi K, Kaneshige K, Suddath WO, Kent KM, Satler LF, Pichard AD, Waksman R. Effect of insurance type on adverse cardiac events after percutaneous coronary intervention. Am J Cardiol. 2011;107:675–680. doi: 10.1016/j.amjcard.2010.10.041. 10. Lurie N, Ward NB, Shapiro MF, Brook RH. Termination from Medi-Cal– does it affect health? N Engl J Med. 1984;311:480–484. doi: 10.1056/ NEJM198408163110734. 11. Fihn SD, Wicher JB. Withdrawing routine outpatient medical services: effects on access and health. J Gen Intern Med. 1988;3:356–362. 12. Tumin D, Foraker RE, Smith S, Tobias JD, Hayes D Jr. Health in surance trajectories and long-term survival after heart transplantation. Circ Cardiovasc Qual Outcomes. 2016;9:576–584. doi: 10.1161/ CIRCOUTCOMES.116.003067.
Repealing the Affordable Care Act: America's Moral Test William B. Borden and Brahmajee K. Nallamothu
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Circ Cardiovasc Qual Outcomes. 2017;10: doi: 10.1161/CIRCOUTCOMES.117.003598 Circulation: Cardiovascular Quality and Outcomes is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2017 American Heart Association, Inc. All rights reserved. Print ISSN: 1941-7705. Online ISSN: 1941-7713
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