JAMA on the ACA

In the current issue of JAMA for the first time in its history there is an article by the current President, or at least it has the individual's name attributed to it. One wonders if it were written solely by the alleged author, since there is no reference of any other contributor. I will let history deal with that fact.

The article summarizes as follows:

Policy makers should build on progress made by the Affordable Care Act by continuing to implement the Health Insurance Marketplaces and delivery system reform, increasing federal financial assistance for Marketplace enrollees, introducing a public plan option in areas lacking individual market competition, and taking actions to reduce prescription drug costs. Although partisanship and special interest opposition remain, experience with the Affordable Care Act demonstrates that positive change is achievable on some of the nation’s most complex challenges.

Has the ACA made a difference? In some ways yes, but generally not for the better. Has it extended health care to many via Medicaid? Yes, and a very low costs but at a likewise low access. So where does the money come from? One source is increases to Medicare payments, especially from those over 65. A full time working 70 year old is paying a total of well over $20,000 per year for a husband and wife, including Medicare Excess, Medicare, and Medicare Plus! The average per person expenditure for Medicare is about $16,000. That is $32,000 per husband and wife. Yet they are paying well about two thirds of that on an ongoing basis! Some deal, wait till you are 75!

It then states several conclusions:

First, many of the reforms introduced in recent years are still some years from reaching their maximum effect...

Yes, many reforms are still in process. Reforms like denying surgerry  for prostate cancer, and other potentially costly procedures for Medicare patients. Then just look at teachers in West Virginia, the state teachers plan is worse than Medicaid, and costs orders more!

Second, while the ACA has greatly improved the affordability of health insurance coverage, surveys indicate that many of the remaining uninsured individuals want coverage but still report being unable to afford it.<sup>...

Affordability? Frankly it is allowing Millennials to now live with their parents and get their grand parents to pay for the deal of a health care plan. Grandma pays $10,000 after paying in for 50 years and the millennial get by with $29 per month while exploring life!</sup>

 Third, more can and should be done to enhance competition in the Marketplaces. For most Americans in most places, the Marketplaces are working. The ACA supports competition and has encouraged the entry of hospital-based plans, Medicaid managed care plans, and other plans into new areas...

 Yes, the marketplace is a mess. Trying to get a bid on a health care plan is more complex that setting up multiple crude oil contracts across seven currencies. Try it! Prof Herzlinger at HBS has a great piesce in the same issue on this point.

Fourth, although the ACA included policies to help address prescription drug costs, like more substantial Medicaid rebates and the creation of a pathway for approval of biosimilar drugs, those costs remain a concern for Americans, employers, and taxpayers alike

Drugs are a mess. Yes a total mess. Why, for several reasons. One, the FDA, in its attempt to be safe may have increased costs dramatically. Second, we are subsidizing drug costs for other countries. Third, Medicare should be able to negotiate. Fourth, the new drugs mabs and nibs are very costly to deal with cancers and other diseases. The costs is due to the need for complex and long lasting trials. Is there a solution to the trial issue? I cannot see an easy one.

Overall one has to ask why JAMA has done this? Policy is important, but a debate is essential. Taking sides may very well be regretted in the long run.