The Affordable Care Act (ACA) provides an unprecedented opportunity to expand insurance coverage and to reform the health care delivery system in the United States. The political debate about its merits and shortcomings has been highly partisan and unrelenting and not particularly evidence-based. With the most significant portion of the health insurance coverage expansion scheduled to begin on January 1, 2014, we can expect more of the same for some time to come. Ultimately, the best way to trump the inevitable unsubstantiated rhetoric is through evidence acquired through the performance of rigorous and objective scientific studies.
The investigators who focus on questions related to the performance of the health care system are health services researchers. The origins of health services research as a scientific field of inquiry dates back to the 1960s, when several key academic leaders from a small number of institutions developed conceptual approaches to studying important questions about access, cost, and quality of care.
The number of investigators has grown over time, but their work is hampered by federal research funding that is available in relatively small amounts and fluctuates with the annual appropriations process. The Agency for Healthcare Research and Quality (AHRQ), the lead federal agency for health services research, had an annual budget of $400 million in 2012, which was approximately 1% of the $32 billion spent by the National Institutes of Health on research related to specific diseases in the same year.
Given the $1 trillion investment the federal government is making to expand insurance coverage through the ACA, it would seem to be an appropriate time to reconsider the budget available to monitor the policy’s effect. The ACA established the Center for Medicare and Medicaid Innovation to test new payment models and the diffusion of promising new models of health care delivery that can improve quality and lower cost. It also established the Patient-Centered Outcomes Research Institute to support studies of comparative effectiveness of treatment options. However, the AHRQ remains the only federal agency designed to leverage the expertise of the research community in developing tools and strategies to conduct an unbiased assessment of the health care system’s overall performance.
But whatever the amount of the available resources for health services research, it is imperative that they be used wisely to yield a meaningful evaluation of the ACA’s effects. Clarity is needed on how best to measure the intervention of insurance expansion and the outcomes it produces. Studies that demonstrate the mechanisms of action between intervention and outcomes will increase confidence in the validity of the findings. For example, because health insurance is a financial tool, we might expect that if the ACA is successful, it will lower the rate at which individuals experience financial hardships, as reflected in bankruptcies related to medical expenses. Successful coverage expansion should also lower financial barriers to receiving care, as reflected in a measure such as the percentage of the population who have a primary care visit in a year.
Less clear is whether and how the ACA will contribute to a change in the anticipated growth of health care costs over time. Will coverage expansion merely increase demand for services, or will it produce off-setting savings by supporting a more efficient way of delivering those services through primary care rather than through emergency department visits or hospitalizations? There are also reasons to be skeptical about whether we should expect health improvements with health insurance expansion. Health care is a relatively minor contributor to health outcomes when compared with the effects of education, socioeconomic status, physical activity, and a variety of health behaviors.
Because the ACA is not being implemented as part of a randomized experiment, assessing its effects will be challenging. Attempts to attribute changes over time in the performance of the US health care system to the ACA will require an accurate assessment of the baseline performance of our health care system before its implementation and also will be confounded by changes over time in the natural history of what would have happened regardless of the ACA becoming law. Furthermore, the ACA’s effects are likely to vary greatly across communities that have had greater or lesser resources available to care for the uninsured through a safety net and differences in other health care characteristics, such as the number of available doctors per capita. We will want to know not only the average effect of the ACA on a national level, but also the degree of variation from that mean across states and local communities. This endeavor creates sample size and research design challenges to ensuring reliable estimates at each unit of analysis.
Perhaps the greatest challenge health services researchers will face in evaluating the ACA is in providing a timely answer. Given the political and financial context associated with implementing the ACA, any void resulting from a lack of data is sure to be filled by the voices of those who are less likely to be concerned about an objective truth than they are with their own special interests. The shaping of public opinion through anecdotes and hyperbole during this time may prove difficult to overcome even by well-performed studies if it takes years to get the results.
Health services researchers face a great challenge. It will prove to be the field’s finest hour if investigators can produce timely, accurate, and meaningful results that can help monitor federal health care policy and, if necessary, amend it. However, if they fail to produce rapid results and engage in the public discourse about the law’s effects, this failure may raise damaging questions about the value and future of the field.
About the author: Andrew Bindman, MD, is Professor of Medicine, Health Policy, Epidemiology and Biostatistics at University of California San Francisco (UCSF). He is the founder and Director of the University of California Medicaid Research Institute, a multicampus research program that supports the translation of research into policy.
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