Editor’s note: The American College of Surgeons (ACS) Board of Governors has conducted an annual survey of its members for more than 20 years. The purpose of the survey is to provide a means of communicating the Governors’ concerns to the ACS leadership. The 2015 ACS Governors Survey, which was conducted in August of 2015, had a 76.2 percent (208/273) response rate.
The following article focuses on the Affordable Care Act (ACA) and is the second in a series of three feature articles highlighting key issues addressed in the Governors survey. The first article was published in the April issue and focused on the electronic health record. The third article will center on graduate medical education.
The ACA, signed into law by President Obama on March 23, 2010, is the most significant piece of health care legislation since the Social Security Amendments of 1965, which enacted the Medicare and Medicaid programs.1 The aims of the ACA include reducing the number of uninsured Americans, controlling the costs of health care, and improving the quality of patient care.
Number of uninsured patients
The ACA seeks to reduce the number of Americans without health care insurance through an expansion of the Medicaid program and the development of health insurance exchanges. These provisions took effect January 1, 2014, and individuals and families were able to begin enrolling in health insurance exchanges as early as October 1, 2013.
The 2015 ACS Governors Survey queried participants regarding the ACA and its effect on access to surgical care nationwide. More than half of the respondents (52 percent) reported that access to surgical care has improved either slightly or significantly, while 19 percent said that access had not changed; 21 percent indicated that access had either decreased slightly or significantly (see Figure 1).
Figure 1. Effect on access to surgical care
A Kaiser Family Foundation report from October 2015 stated that the uninsured rate among the nonelderly population fluctuated between 16.1 percent and 18.2 percent in 2000–2013.2 After the ACA went into effect in January 2014, the Kaiser report—which described the subsequent decrease in uninsured rates as “historic”— revealed that the uninsured rate among the nonelderly population had diminished to 16.2 percent in the last quarter of 2013, with a 12.1 percent rate in the last quarter of 2014, and a 10.7 percent rate in the first quarter of 2015.2 HealthCare.gov—a government website managed by the U.S. Centers for Medicare & Medicaid Services—notes that this reduction in the number of uninsured Americans is the largest in four decades and that approximately 16.4 million previously uninsured people have gained access to health insurance coverage since the passage of the ACA.3
Governors responding to the survey were asked if the percentage of uninsured patients they treat had changed. Although 45 percent of the respondents said that they had not observed a change, 41 percent responded that the number of patients without health care insurance has decreased slightly or significantly; only 8 percent of the respondents said the percentage has increased slightly or significantly (see Figure 2).
Figure 2. Percentage of patients who do not have health care insurance
In addition, 41 percent of the respondents said they had not seen any change in the percentage of patients they treat who have health care insurance since the ACA was enacted. Another 45 percent said that the percentage of patients who had health care insurance had increased slightly or significantly; only 9 percent said the percentage had decreased slightly or significantly (see Figure 3).
Figure 3. Percentage of patients who have health care insurance
The ACA originally required every state to develop and implement an expanded Medicaid program that would allow individuals who earn up to 138 percent of the federal poverty level ($27,000 annually for a family of three) to secure health care coverage through the federal-state program.4 However, while the U.S. Supreme Court upheld the major provisions of the ACA, on June 28, 2012, it made Medicaid expansion by states voluntary.5 At present, 31 states and the District of Columbia have chosen to expand Medicaid.3 Since the open enrollment period for the ACA began, Medicaid enrollment has grown by 14 million people, an increase of 23 percent (see related article).2
Although 45 percent of the respondents to the Governors survey said that they had not noted any change in the percentage of Medicaid patients whom they treated, 46 percent of the respondents stated that the percentage of Medicaid patients had either increased slightly or significantly, and only 3 percent said that the percentage had decreased slightly or significantly (see Figure 4).
Figure 4. Percentage of Medicaid patients
Higher health insurance premiums have become a fact of life. A June 2015 Forbes article noted the average health insurance premium increase for a family policy ranged from 3 percent to 9.5 percent in 2005 to 2014 (see Figure 5).7
Figure 5. Average health insurance premium increases (family premium)
In 2011, the year after the ACA was signed into law, family plan premiums increased an average of 9.5 percent.
To decrease the monthly premium, some individuals who purchase their own health insurance may choose a plan that has a higher deductible. Many individuals with employer-based health insurance coverage have had to accept a plan with a higher deductible as a result of the cost-sharing practices used by many employers.
The ACA also may be playing a role in driving up deductibles because individuals who previously were unable to afford health care insurance or chose not to carry health care insurance may now purchase policies with a high deductible in exchange for a lower monthly premium payment.
Effects of higher deductibles
The survey asked Governors whether higher deductibles seem to be affecting patients’ decisions regarding elective surgical procedures. Although 49 percent of the respondents noted no change in patient decisions, 44 percent reported that a slightly higher or significantly higher percentage of patients were delaying elective operations since implementation of the ACA; only 7 percent of the respondents reported a slightly higher or significantly higher percentage of patients were scheduling their elective surgery more quickly (see Figure 6).
Figure 6. Patient decisions regarding elective surgery
Because more Americans now have health insurance, one might assume that patients who previously were uninsured now present to their surgeon at an earlier stage of illness. On the other hand, some patients with higher deductible payments might delay their initial evaluation for a surgical disease and therefore present at a later stage of disease.
Of the Governors who responded to the survey, 67 percent reported no change in the stage of disease at presentation, and 26 percent responded that a slightly higher or significantly higher percentage of patients were presenting at a more advanced stage of disease; only 7 percent indicated that a slightly higher or significantly higher percentage of patients were presenting at an earlier stage of disease (see Figure 7).
Figure 7. Are patients presenting at a different stage of disease?
When patients have health insurance policies with higher deductible limits, one might assume that it would be more difficult for surgical practices to collect full payment. Most 2015 ACS Governors Survey respondents (61 percent) said that they noted no change in their practices’ ability to collect deductible payments, 38 percent responded that it was either slightly harder or significantly harder to collect patient deductibles, and 1 percent stated that it was easier to collect deductibles (see Figure 8).
Figure 8. Ability to collect deductible payments
Effects on volume
With more Americans having health care insurance as a result of the ACA, one might anticipate that more patients are seeking surgical care. Governors were asked if the volume of cases that they manage has changed since implementation of the ACA. More than half (52 percent) reported no effect on surgical volume, 23 percent of the respondents reported a slight or significant increase in surgical volume, and 16 percent indicated a slight or significant decrease in surgical volume has occurred (see Figure 9).
Figure 9. surgical practice volume
Several factors could lead to a decrease in surgical case volume. For example, a higher deductible payment might deter some patients from pursuing surgical treatment for what they perceive to be a minor problem. Another factor could be narrow health insurance networks. A study by the McKinsey & Company’s Center for U.S. Health System Reform examined hospital network data from 120 unique 2014 individual exchange market products in the silver tier offered by 80 carriers. This analysis spanned 20 urban rating areas and included close to one-fourth of the U.S. nonelderly uninsured population.8 According to the study’s findings, 70 percent of the hospital networks in the exchanges were either narrow or ultra-narrow, which might eliminate some surgeons from the network.
One of the major goals of the ACA was to decrease the number of Americans without health care insurance. Responses from the 2015 ACS Governors Survey, which was administered a year and a half after enrollment in the ACA began, show that this goal is being met. The ACS Governors generally reported improved access to care nationwide, an increase in the number of patients who have health insurance, an increase in the number of patients who have Medicaid coverage, and a slight increase in caseload.
One might assume that increased access to care and an increased number of patients with some form of health care insurance would lead to overall improved quality of care for surgical patients. However, the survey data do not definitively support this assumption. Since the inception of the ACA, according to survey respondents, a higher percentage of patients were delaying their elective surgery and a higher percentage of patients were presenting at a later, rather than an earlier, stage of disease.
The ACA will continue to affect the surgical care of patients in the U.S. for years to come. The Governors anticipate that the ACS leadership will be able to use the results from this survey in its efforts to improve access to quality care for surgical patients nationwide.
- H.R. 3590: Patient Protection and Affordable Care Act. (111th). Available at: www.govtrack.us/congress/bills/111/hr3590. Accessed March 16, 2016.
- Kaiser Family Foundation. Key Facts about the uninsured population. October 5, 2015. Available at: http://kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/. Accessed March 16, 2016.
- U.S. Department of Health & Human Services. The Affordable Care Act is working. June 24, 2015. Available at: www.hhs.gov/healthcare/facts-and-features/fact-sheets/aca-is-working/index.html. Accessed March 16, 2016.
- Kaiser Family Foundation. The coverage gap: Uninsured poor adults in states that do not expand Medicaid. October 2013. Available at: https://kaiserfamilyfoundation.files.wordpress.com/2013/10/8505-the-coverage-gap-uninsured-poor-adults8.pdf. Accessed March 16, 2016.
- U.S. Supreme Court. National Federation of Independent Business vs. Sebelius. October 2011. Available at: www.supremecourt.gov/opinions/11pdf/11-393c3a2.pdf. Accessed March 16, 2016.
- Rudowitz R, Snyder L, Smith V. The Kaiser Commission on Medicaid and the Uninsured: Medicaid enrollment and spending growth: FY 2015 and 2016. Available at: http://kff.org/medicaid/issue-brief/medicaid-enrollment-spending-growth-fy-2015-2016/. Accessed March 30, 2016.
- Patton M. Health insurance premiums are rising faster than income. Forbes. June 30, 2015. Available at: www.forbes.com/sites/mikepatton/2015/06/30/health-insurance-premiums-are-rising-faster-than-income/#5cc1ce211eb5. Accessed March 16, 2016.
- McKinsey & Company. Hospital networks: Configurations on the exchanges and their impact on premiums. December 14, 2013. Available at: http://healthcare.mckinsey.com/sites/default/files/Hospital_Networks_Configurations_on_the_Exchanges_and_Their_Impact_on_Premiums.pdf. Accessed March 16, 2016.