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final hrKurt A. Yaeger, MD (left)
Neurosurgical Resident, Mt. Sinai Hospital
New York, NY

Clemens M. Schirmer, MD, PhD, FAANS, FAHA (right)
Vice-Chair, AANS/CNS Communications and Public Relations Committee
Geisinger Health System
Wilkes Barre, PA

hc3 fianl 30In March and April, Neurosurgery Blog considered various aspects of the Affordable Care Act (ACA). Clearly, the signs are pointing towards change, and even though the first major Republican proposal, the American Health Care Act (AHCA), barely squeaked through the House of Representatives, it’s certainly not going to be the last word on health reform; thus it is worth focusing on the fundamentals. Looking back, when fashioning major U.S. health care reform in the early days of President Barack Obama’s first administration in 2008, policymakers maintained one overarching principle: to improve access to quality and affordable health care. In a 2008 article published in the journal Health Affairs, Donald Berwick, MD, MPP, FRCP, and coauthors posited that “improving the U.S. health care system requires simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health care.” The costs of such a system were to be driven down by increasing the number of people in the insurance market through an individual mandate, enhancing the efficiency of health care, and focusing on preventive care and chronic disease. Medical professionals and health policymakers recognized that the “proliferation of high-end health care… led to an increased demand on health care, resulting in cost escalation,” and this “runaway overutilization of [U.S.] health care was unsustainable.”

Reform was inevitable, but it took a U.S. political overhaul in the 2008 presidential election to stimulate definitive action. Even before the signing of the ACA in 2010, the reform was met with controversy from all political lines. Throughout this period, organized neurosurgery has been at the forefront of policy development. The philosophy of expanding access to quality, cost-effective neurosurgical care has remained constant and will continue to drive legislative efforts as the new health care reform proposals evolve.

Before Contemporary Health Reform 

Following its introduction in 1965, the U.S. Medicare system has adopted several critical revisions, including the addition of payments to managed care plans in 1997 (Medicare Part C) and prescription drug coverage in 2006 (Medicare part D). For physicians, a monumental change was introduced in 1992 with the development of a resource-based relative value scale (RBRVS), which based payments on the resource costs associated with a particular service. In 1997, the sustainable growth rate (SGR) formula was introduced to limit physician spending and ensure that the annual increase in health care spending per Medicare beneficiary did not exceed the growth in Gross Domestic Product (GDP). Since this formula was based entirely on estimated changes in fees for physicians’ services, it was inherently flawed, and eventually required compensatory cuts in physician payments. In the years following the introduction of this fee-for-service model, U.S. health care spending increased along an unsustainable trajectory. Barack Obama was elected as president in 2008 in part for his pledge to revamp the U.S. health care sector and provide universal health care coverage to U.S. citizens.

Transition to Reform

With the signing of the ACA on March 23, 2010, the U.S. health care system ushered in an era of accountability for providers to deliver quality and efficient care. With an emphasis on pay-for- performance, rather than on a fee-for-service basis, many physicians, including subspecialty providers, were required to begin adopting new cost-effective practice models. Since the inception of the ACA, organized neurosurgery has been highly active in the dynamic shaping of U.S. health care reform, with the goal of improving access to quality neurosurgical care across the country. Marc A. Vanefsky, MD, FAANS, then-president of the California Association of Neurological Surgeons, stated “it is no longer enough to say ‘I am just the neurosurgeon’… Organized Neurosurgery has a responsibility to continue to influence healthcare legislation to make sure that we can continue to provide the highest quality care to our patients.”

In April 2010, organized neurosurgery published its perspective on the recently approved ACA. The list of reform priorities included covering the uninsured, lowering health care costs, preventing a single payer system, ensuring direct access to subspecialty care, as well as limiting the role of government in residency training. Importantly, neurosurgery also commented that the provision of quality should be determined by the profession. This commentary also addressed concerns about the establishment of the Independent Payment Advisory Board (IPAB), a politically appointed committee that would have vast authority to determine Medicare payment rates. This early perspective about the ACA by members of organized neurosurgery cited few elements of “good news” about the ACA — primarily that it was not based on a single-payer model. The list of “bad news” was considerable; an overarching concern was focused on the expansion of Medicaid, the potential future reimbursement battle with primary care physicians, and the undervaluing of the physician fee schedule with regards to subspecialty care. AANS and CNS also believed that there was not enough emphasis on medical liability reform, obviously a critical factor in a neurosurgeon’s practice.

Neurosurgery’s concerns were echoed throughout the medical profession and beyond, and the health care law was first challenged in Florida in January 2011. Elements of the law were ruled unconstitutional, specifically the individual mandate and Medicaid expansion, and twenty-five other states soon followed suit. In November 2011, the challenge was brought to the U.S. Supreme Court in the case National Federation of Independent Business v. Sebelius, and on June 28, 2012, the Court ruled that the mandate to purchase health insurance was a valid exercise of Congress’s power under the Taxing Clause.

Subsequently, the constitutionality of the ACA’s insurance premium tax credits for individuals obtaining insurance through federal exchange plans was challenged in the U.S. Supreme Court in the case of King v. Burwell. On June 25, 2015, the case was affirmed by a vote of 6-3, allowing such federal subsidies. In light of this resolution, the AANS and CNS called upon Congress to “increase consumer choice beyond the current government mandated plans, by allowing individuals to choose plans such as health savings accounts.”

Present Reform Landscape

The ACA has been a politically dichotomous issue throughout its existence. As such, on Nov. 8, 2016, health care reform was launched into uncertainty with the presidential election of Donald Trump. President Trump’s first executive order, signed on inauguration day, was entitled the “Executive Order Minimizing the Economic Burden of the Patient Protection and Affordable Care Act Pending Repeal.” Less than a week later, Barack Obama cautioned the new administration’s “Repeal then Replace” policy in an editorial in the New England Journal of Medicine. “What the past 8 years have taught us,” he states, “is that health care reform requires an evidence-based, careful approach, driven by what is best for the American people. That is why Republicans’ plan to repeal the ACA with no plan to replace and improve it is so reckless. Rather than jeopardize financial security and access to care for tens of millions of Americans, policymakers should develop a plan to build on what works before they unravel what is in place.”

Even as the health reform debates continues, what remains constant is the effort of organized neurosurgery to help shape the course of health care reform. The recently published AANS and CNS 2017 Legislative and Regulatory Agenda advocates for policy change on behalf of neurosurgeons and their patients throughout the country. Importantly, there remains a consistent support for “expanding the access to affordable health insurance coverage for all Americans.” This philosophy should remain at the forefront of all future endeavors in this dynamic health care reform landscape.

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