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INTRODUCTION

There is no shortage of speculation about the future of the U.S. health system. The mainstream media, bloggers, futurists, and pundits are fast and eager to not only predict the system’s future, but also to fit today’s unfolding events to their own narrative of the subject. Decisions made and policies deployed now, often with incomplete information and understanding, could have outsized and dramatic effects on our future health and economy. However, how sure can we really be of what the future will hold for patients and providers?

Healthcare delivery and policy have already sustained several recent cataclysmic changes. First, in 2003, Congress passed the Medicare Prescription Drug, Improvement, and Modernization Act. This act created Medicare Advantage, a program of tremendous importance to today’s healthcare environment. Medicare Advantage, or Part C, represented an important evolution of non-fee-for-service options for Medicare beneficiaries. Then came the Affordable Care Act (ACA). The ACA, or the Patient Protection and Affordable Care Act, was landmark legislation passed on March 23, 2010, and it largely came into effect in 2014. The law was the first major expansion of healthcare coverage in the United States since the creation of Medicare and Medicaid in 1965. Largely due to expansions in Medicaid eligibility and the creation of insurance markets, the numbers of uninsured Americans rapidly fell.1,2 While many of the great gains in insurance coverage were made due to Medicaid expansion, the law also created insurance markets in order to make available insurance premiums with a standardized list of essential health benefits to all, regardless of preexisting health conditions. The law also made several major changes to healthcare delivery, including:

  • incentives and penalties for hospital readmissions among Medicare beneficiaries.

  • penalties for hospitals for hospital-acquired conditions and patient harms

  • pay-for-performance payment incentives for hospitals and physician practices.

  • an experiment around bundling payments for care across hospitals, physician organizations, and posthospital care.

  • a new type of care organization, the Accountable Care Organization (ACO), that integrated care and payment across outpatient, inpatient, and post-hospitalization services. Groups that formed ACOs could share in savings incurred by better-coordinated and higher-value care through participation in the Medicare Shared Savings Program (MSSP). Organizations willing to incur some of the risk could also participate as Pioneer ACOs.

  • increased funding to the National Health Services Corps.

  • the Center for Medicare and Medicaid Innovation, to further put in place experiments in healthcare payments to increase value for beneficiaries of Medicare and Medicaid.

  • the Patient-Centered Outcomes Research Trust Fund, which supports the Patient-Centered Outcomes Research Institute, a grant-giving and research organization.

Key Point image

Healthcare is moving toward value-based care, even though most U.S. healthcare remains fee-for-service in 2019.

What do these transformative laws mean for the care that our children will receive? Themes are evolving both within and outside healthcare that are a prelude, if not a preview, to what will come in the near and distant future. Some of these drivers are ...

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