As Premiums Jump, Conference Considers Obamacare’s Performance

Axelrod, Goolsbee, and UCMC head consider Affordable Care Act’s promise and danger.

An all-star cast of University of Chicago experts on health care gathered downtown Monday for a Halloween-themed take on President Barack Obama’s chief domestic accomplishment, the Affordable Care Act (ACA). 

Panelists at the event, titled “The Affordable Care Act: Trick or Treat?” included Obama’s chief political advisor, the head of his Council of Economic Advisors, University of Chicago economists, and representatives of the University of Chicago Medical Center (UCMC). Steep hikes in premiums on ACA-created health-care marketplaces announced earlier this month rocked the presidential election and prompted concerns about the sustainability of the law.

The conference began with a panel titled “Policy, Politics, and Law.” Featured guests were Law School professor Jennifer Nou, Director of the Institute of Politics David Axelrod, and Harvard School of Public Health professor Thomas Lee. Booth School professor Austan Goolsbee moderated the discussion. Goolsbee and Axelrod were prominent figures in the Obama administration, Goolsbee as Chair of Obama’s Council of Economic Advisors and Axelrod as Obama’s Senior Advisor.

“Obamacare is under duress, but I am optimistic,” Lee said. In Lee’s view, the new system is displaying turbulence because it is still in an adjustment period. He predicted that this period could end in one to two years. What comes out of this “settling down,” as he called it, will be a better system.

Nou, evaluating the ACA from a legal perspective, acknowledged that because the Supreme Court upheld the ACA’s constitutionality, its framework is protected to an extent. Yet, pending litigations surrounding the ACA still contribute considerable uncertainty to its future. Zubik v. Burwell, a case challenging the religious exemption from the Act’s contraceptive mandate, is one example of consequential legal debates that could either broaden or constrain the ACA’s influence.

Politically, the public has a mistaken perception of the ACA, said Axelrod, in that they see it as only usurping the wealth of some to alleviate the plight of others. The misunderstanding has fueled opposition to the ACA and created a formidable obstacle to the Act’s success, he said. Axelrod said he believes that conveying the truthful and complete content of the ACA, especially to young and healthy Americans, should be a priority going forward.

The public’s reception to the ACA can be equally contingent on their emotional attachment to the status quo, or Medicare. Axelrod observed a paradox when he said, “Our results are not good, our costs are too high…and yet people still [say] don’t temper with [Medicare], because the American system is the best.”

The second panel focused on the medical impact of the ACA. Moderator David Song, CEO of the Permanente Group Robert Pearl, CEO of the American Medical Association James Madara, and Executive Director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania Daniel Polsky spoke about a range of topics including the effect of the ACA on the health of the population as well as end-of-life care and the future of the medical field.

“As a practicing physician, I saw about twenty patients in the morning, and [this discussion] is absolutely germane and near and dear to everyone in this room,” Song said. “This is something that is consuming everybody in this country.”

Because many of the panelists agreed it was too early to see the full impact of the law on the population as a whole, Polsky spoke about the improvements he saw in the Oregon Health Experiment and Pearl spoke about the impact that Kaiser Permanente has seen from its patients who have benefited from affordable care.

He said the issue is “not the 5% but the 95%.” 

“We’ve changed the health of those patients for the better but does that change the American health care system? No. It’s too small a number,” he said. 

The panel also discussed end-of-life care and a shift from “volume to value” that Polsky believes gives patients more choices at the end of their lives. As a professor at UPenn, Polsky also spoke about how the ACA will affect future generations of students who hope to become physicians.

The panel hoped to highlight the implications of the law and answer the question of whether the law should be left alone, modified, or repealed. 

Pearl called for further change, an “evolution in medical healthcare” through the use of technology.

“Rather than blaming it, we have to understand its power, and figure out how to harness that,” he said. 

The third panel covered the Act’s economic impact in theory and practice with School of Social Service Administration professor Harold Pollack and UCMC head Kenneth Polonsky. David Meltzer, an economist, medical internist and Chief of the Section of Hospital Medicine at the University of Chicago, moderated the panel.

Pollack’s take on the Act was broadly positive, though he acknowledged that further steps might have to be taken to fill in the gaps left by the plan. 

“There’s no question that we face challenges in the implementation of the ACA, but it’s really a historic accomplishment in terms of bolstering our safety net,” Pollack said. “I think it’s important to note that the ACA has been, for poor and sick people in particular, an important accomplishment.”

Pollack especially emphasized the expansion of Medicare to all low-income people as a central advantage secured by the ACA. He noted, however, that the decision of many states to refuse the Medicare expansion, and structure of the insurance exchanges, left some patients in a lurch.

“Those of us who are very proud of [the ACA] and worked to enact it, it is important we acknowledge the difficulties it encountered, and not fall prey to trying to somehow paper these over,” Pollack said.

Polonsky said he also saw positive aspects of the ACA, but noted that “the jury is still out” on some of the structural changes the ACA encouraged. As an example, he noted that Act encouraged hospitals like UCMC to expand to become larger networks. He linked this element of the Act to UCMC’s decision to merge with Ingalls Health System in Chicago’s southern suburbs this year.

“Will these large health systems and these large physician groups deliver better care, more efficiently, more cost effectively, and with better quality than the smaller groups and the isolated hospitals? I think everybody hopes that that will be the case, but it’s still a work in progress,” Polonsky said.

Illinois is fairly stingy in compensating health care providers for working with Medicaid recipients, Polonsky noted, posing a challenge for people obligated to balance fiscal rectitude with their patient’s welfare.

“This is something that is going to have to be addressed. We don’t think that the Affordable Care Act is going away, and we don’t think it should go away, but on the other hand there has to be an economically sustainable model…to take care of these vulnerable populations and poor people in a way that one can at least approach break even,” Polonsky said.