The number of uninsured Americans has dropped to a historic 9.1 percent since the enactment of the Affordable Care Act six years ago.

According to the U.S. Department of Health & Human Services, an estimated 20 million people have gained health insurance coverage between the passage of the law in 2010 and March of this year.

“Our country has made undeniable and historic strides thanks to the Affordable Care Act,” HHS Secretary Sylvia M. Burwell said earlier this month, noting that for the first time in our history, fewer than one in 10 Americans lacked health insurance.

“Our country ought to be proud of how far we’ve come and where we’re going.”

But 19 states still refuse to expand Medicaid for the poorest of the uninsured. And many low- and middle-income families still find that participating in state exchanges is out of their reach or that the process is just too complex.

Stanford health policy experts, state government officials, mobile health and private health-care executives recently gathered on campus to look at the impact of the Affordable Care Act, six years after its adoption.

The consensus was the Act has done more to grant access to health care for Americans than any other government program since Medicaid was adopted in 1965 to help the poor, and Medicare to subsidize the elderly in 1985.

Yet the law’s initial technical missteps, continuing red tape and opposing provisions — as well as the lack of support by so many states and members of Congress — continue to undermine the Act.

“As most of you know, the heath-care sector in the U.S. is large and extremely complex,” said Mark Duggan, director of the Stanford Institute for Economic Policy Research, which sponsored the conference. He said total health-care spending in 2016 would amount to $3.4 trillion, an average of more than $10,000 per person.

Yet one-third of those health-care costs go to waste, said Thomas Goetz, co-founder and CEO of the health-care startup Iodine, which uses apps and data visualization to better inform consumers about their health-care and drug choices.

Goetz told the audience of faculty and students that medication — for depression and anxiety, chronic pain and autoimmune diseases — are typically ineffective up to 50 percent of the time.

“The solution isn’t more randomized clinical trials,” said Goetz, whose company recently launched an app that allows users to take a depression test and decide which antidepressant might work best for them. “The goal is to look at patients as consumers and catalysts — versus patients as passive.”

But has the ACA been effective? It seems the reviews are still mixed.

Kate Bundorf, associate professor of health research and policy at the School of Medicine, noted that this an exciting time for policymakers because the evidence on the effects of the Affordable Care Act is starting to emerge.

She said the Congressional Budget Office estimates that the coverage provisions of the ACA increased government spending by $110 billion and reduced the number of uninsured by 22 million in 2016.

While many analysts were concerned that employers might drop health insurance for workers in response to the subsidies for coverage available through the exchanges, employment-based coverage has remained stable.

Whether the ACA has slowed the rate of growth of health-care spending is still up for debate.

While spending did slow down around the time of the Act’s implementation, it is difficult to determine whether the lag was caused by the ACA’s provisions or other factors such as the recession or increases in cost-sharing for private insurance. And the most recent estimates indicate the rates of growth in spending have begun to increase, possibly signaling a return to historical levels, Bundorf said.

“The big surprise was that not all states expanded Medicaid, with the Court ruling allowing states to opt out,” said Bundorf, who is also a senior SIEPR fellow.

The Supreme Court ruled in 2012 that states could decide individually whether to expand the Medicaid insurance program for the poor.

John Bertko, chief actuary for California’s health exchange, Covered California, describes the Affordable Care Act “as actuarial puzzle to work on every day.”

He should know. Bertko worked on the Obamacare actuarial tables for three years.

One of the most significant changes to the American health-insurance system, he said, are those 32 states that expanded Medicaid under the the ACA. Americans who earn less than 138 percent of the federal poverty level now qualified for Medicaid and the Children’s Health Insurance Program.

Just as the Medicaid expansion went into effect in 2014, a provision of ACA also increased payments for primary care physicians who accepted Medicaid. However, for budgetary reasons, those increased payments only lasted for two years.

“So you have this huge expansion of the number of people qualifying for Medicaid and at the same time payments for suppliers dropped down,” he said. “So lots of Medicaid card carriers were left floating around looking for providers.”

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“When you insure people, you’re going to increase costs and the costs have gone up,” said Bhattacharya, a core faculty member of Stanford Health Policy and senior fellow at SIEPR and the Freeman Spogli Institute for International Studies.

“The total expenditure on the poor, the costs have gone up,” Bhattacharya said. He added here has been no change in the mortality rate of Americans since adoption of the Act. “It’s difficult to find mortality benefits from the social benefits.

Larry Levitt, senior vice president for special initiatives at the Kaiser Family Foundation, reminded the audience the main goal of the ACA was to expand insurance coverage for Americans.

“And it certainly has been a success at doing that,” he said.

Still, Levitt added, roughly 30 million non-elderly Americans remain uninsured. And many of those who are insured are opting for high-deductible plans to keep their monthly premiums down.

“Twenty percent of people who are insured say they have a problem paying their medical bills because they don’t have a lot of money in the bank and have large deductibles,” he said.

If the other states would follow the lead of the top 10 states leading the way on ACA enrollment, Levitt said, there would be a great improvement overall.

Bundorf said the so-called Cadillac Tax would raise some revenue and the incentive to create more employee-sponsored insurance plans.

But the highly contentious levy that was supposed to go into effect in 2018 has bene delayed to 2020 while Congress, the IRS, unions and big business debate its fairness.

The provision of Obamacare would impose a 40 percent excise tax on the portion of most employer-sponsored health coverage that exceed $10,200 a year and $27,500 for families. The goal is to control the growth of health-care spending by eliminating pricier benefit plans and curtail excessive health-care use.

“The problem with the Cadillac Tax is that, with time, it becomes the Chevy tax,” said Levitt. “I don’t think it will ever go into effect — but it will precipitate something that can replace it.”

On May 27, 2016, President Obama will become the first sitting president to visit Hiroshima. In light of this historic visit, SPICE hosted a webinar on May 23, 2016, which featured the talk, “Beneath the Mushroom Cloud,” by Clifton Truman Daniel, grandson of President Harry S. Truman and author of Growing Up with My Grandfather: Memories of Harry S Truman. Following a question and answer period with Mr. Daniel, SPICE staff shared classroom resources (Sadako’s Paper Cranes and Lessons of Peace and Divided Memories) that introduced diverse perspectives on the atomic bombing of Hiroshima.

RELATED CLASSROOM RESOURCES

Hiroshima: Perspectives of the Atomic Bombing
Divided Memories: Comparing History Textbooks
Examining Long-term Radiation Effects
Nuclear Tipping Point (video)
Sadako's Paper Cranes and Lessons of Peace
Reflections from an Atomic Bomb Survivor (video)

This webinar is being offered in collaboration with the National Consortium for Teaching about Asia, which is funded by the Freeman Foundation. The NCTA is a multi-year initiative to encourage and facilitate teaching and learning about East Asia in elementary and secondary schools nationwide.

Triage nurses typically assign patients to emergency room doctors who are on call or working a shift. But what if the doctors themselves determine whom among them is better suited to take on the next patient?

Classic economic theory predicts “moral hazard” in teams, which means one member behaves inefficiently because in the end someone else will pay the consequences. Yet many successful organizations promote teamwork.

So how does this puzzle relate to health care?

This is the question that Assistant Professor of Medicine David Chan, a core faculty member at Stanford Health Policy, tackles in his new study in the Journal of Political Economy.

Emergency departments (ED) nationwide cost a combined $136 billion to run each year, significantly impacting the growing health-care sector of the U.S. economy. Visits to the emergency rooms are increasing despite the implementation of the Affordable Care Act, causing them to be overcrowded and underfunded.

Chan studied two organizational models: one in which physicians are assigned patients in a nurse-managed system and one in which the doctors divide patients among themselves in a self-managed system.

“I find evidence that physicians in the same location have better information about each other and that, in the self-managed system, they use this information to assign patients,” Chan writes.

He said that by simply allowing physicians to choose patients, a self-managed system reduces emergency room lengths of stay by 11-15 percent, relative to the nurse-managed system.

“This effect occurs primarily by reducing a `foot-dragging’ moral hazard, in which physicians delay patient discharge to forestall new work,” Chan writes. A triage nurse is often in another room and has a difficult time observing true physician workload, whereas peer physicians who work together can.

“So, for example, if there are two physicians working at a time when there are a whole bunch of patients in the waiting room, then each physician knows that the minute he discharges a patient, he is more likely to get another one,” Chan said in an interview. This might lead the physician to dilly-dally on the release of that patient, knowing that he’ll immediately be signed another before he gets a break.

However, two physicians who can observe how busy the other one truly is will be less likely to stall, even if they want to avoid new patients.

Chan studied a large, academic emergency room that treated 380,699 patients over a six-year period. He looked at length of stay, measuring each physician’s individual contribution. He also observed patient demographics and used the Emergency Severity Index, an ED triage algorithm based on a patient’s pain level, mental status, vital signs and medical condition.

Besides measuring the effect of the self-managed system in this large hospital, Chan combined evidence to support the hypothesis that teamwork improves outcomes because of mutual management with better information.

He found that the only difference in outcomes between the two organizational systems was foot-dragging. Clinical outcomes or even the number of tests ordered were about the same under a self-managed or nurse-managed system.

Moreover, the foot-dragging behavior grows as physicians may anticipate future work by the number of patients in the waiting room, even if they end up seeing the same number of patients.

Finally, physicians refrain from this behavior when being watched by another physician in the same location, even in the nurse-managed system, when that other physician does not otherwise have any role in the physician’s patient care.

“I think the biggest takeaway is that such efficiency gains can be widespread in health care, particularly because there is so much at stake hidden behind information in patient care that is not transparent,” Chan said.

“Even if we don’t fully anticipate all of these gains, we could still achieve a lot by tinkering and using these changes as natural experiments to figure out what works and what doesn’t,” Chan said. “We can further use these results, particularly the evidence pointing at a mechanism, to think of what other innovations might work.”

The U.S. government has invested $1.4 billion in HIV prevention programs that promote sexual abstinence and marital fidelity, but there is no evidence that these programs have been effective at changing sexual behavior and reducing HIV risk, according to a new Stanford University School of Medicine study.

Previously: PEPFAR has saved lives – and not just from HIV/AIDS, Stanford study finds
 

Americans spent $3 trillion on health care in 2014, or about $9,523 per person. That’s up 5.3 percent from the previous year. That increase isn’t expected to slow down; for about the next decade, the U.S. government  expects spending to grow 5.8 percent on average each year.

As policymakers look for ways to cut down this spending, one idea gaining traction is to incentivize consumer-directed health plans (CDHP). These high-deductible, low-cost plans are already growing in popularity. About 20 percent of people who are covered by employer-sponsored health insurance are enrolled in some type of CDHP.

In theory, CDHPs would reduce health-care costs because consumers would choose less expensive health care when they pay for it themselves. But does that theory pan out in practice? M. Kate Bundorf, an associate professor of political economy, examines the benefits — and the trouble spots. Bundorf is also a core faculty member at Stanford Health Policy.