Author Archives: Brendan Saloner

The Unfinished Work of the Affordable Care Act

Dec 12, 2014, 8:45 AM, Posted by Brendan Saloner

The United States is the last remaining rich country in the world where a large percentage of the population lacks health insurance coverage. This situation is being improved under the Affordable Care Act (ACA), with recent estimates showing that from early 2013 to mid-2014 the uninsured rate dropped from 19 percent of adults to 14 percent. The uninsured rate will no doubt continue to fall in 2015, but the problem of the uninsured will not go away with the ACA. It will not go away even if all 50 states expand Medicaid for poor adults, and will not go away if the U.S. Supreme Court rules against the plaintiffs in a pending challenge to the power of the administration to provide subsidies in the federally facilitated insurance exchanges.

In its 2012 baseline estimate, the Congressional Budget Office (CBO) projected that by 2022 the ACA might cut the number of uninsured by half, but would still leave behind 30 million people without insurance. This projection assumed full implementation of the ACA provisions. We don’t yet have a clear sense of how much larger that number will be with incomplete implementation of the core ACA coverage provisions, but even an optimistic assessment is that tens of millions of Americans will continue to spend periods of time without health insurance.

Who does the ACA leave behind? By design, the ACA excludes undocumented immigrants, a group that numbers around 11 million today. Some undocumented immigrants purchase private insurance, receive coverage from an employer, or participate in public programs funded with non-federal dollars, but the majority have no insurance. Undocumented immigrants are prohibited from enrolling in Medicaid, receiving subsidies, and purchasing coverage on the exchanges. Although President Obama recently signed an executive order protecting many undocumented immigrants from immediate deportation, the ACA exclusion will continue in the foreseeable future, barring an act of Congress. 

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A ‘Goldilocks’ Theorem of Shared Savings and ACOs

Mar 22, 2013, 9:00 AM, Posted by Brendan Saloner

Brendan Saloner, PhD, is a Robert Wood Johnson Foundation (RWJF) Health & Society Scholar in residence at the University of Pennsylvania and a senior fellow at the Leonard Davis Institute of Health Economics. This is the first in a series of essays, reprinted from the Leonard Davis Institute of Health Economics’ eMagazine, in which scholars who attended the recent AcademyHealth National Health Policy Conference reflect on the experience.


Like Goldilocks wandering through the house of the Three Bears, policy-makers in search of a health care payment model have found it difficult to settle on an option that is "just right."

Fee-for-service—paying doctors separately for each service they provide—leads to too much unnecessary and duplicative care (too hot!). Capitation—paying doctors a fixed fee for caring for patients—leads doctors to skimp on care and avoid costly populations (too cold!). A "just right" payment model should give providers incentives to provide all the clinically necessary care to patients while keeping costs low.

Shared savings models—allowing providers to keep a portion of the money they save caring for patients—have been touted as one method for aligning the incentives of providers and payers. Most prominently, shared savings is a central element of the Affordable Care Act's Accountable Care Organizations (ACOs).

An ACO is a network of providers that have agreed to accept a bundled payment for treating patient populations, and in return stand to gain incentive payments for meeting performance targets (or to lose money for missing targets). In the "happily ever after" version of ACOs, groups of providers will finally have a business case for coordinating patient medical records, reducing costly visits to the emergency room, and improving patient compliance with chronic disease therapies without leading to excessive procedures or gaps in care. Healthy patients, healthy profits.

But will it work?

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Let’s Get Serious about Substance Abuse Treatment – Starting with Payment Reform

Jan 3, 2013, 9:00 AM, Posted by Brendan Saloner

Brendan Saloner, PhD, is a Robert Wood Johnson Foundation Health & Society Scholar at the University of Pennsylvania. 

New Year’s resolutions are about fresh starts and new beginnings, and for many Americans that includes the decision to finally give up heavy drug and alcohol use. Unfortunately, when it comes to encouraging individuals to enter treatment, providing counseling, and supporting long-term recovery, our health care system is showing up late to the party.

There are 21 million adults and adolescents with a diagnosable substance abuse problem in the United States, but fewer than one in five receive treatment in a given year. The reasons why people do not get treated are complicated. Many are not ready to give up using substances or don’t recognize they have a problem, but many others are discouraged from seeking treatment because of the cost or the perceived lack of treatment options. Opportunities to raise awareness about treatment are often missed, as primary care doctors infrequently screen for substance abuse during routine visits, and are often unaware of where to refer patients for specialized addiction treatment.

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