In addition, there could be a reduction in services and jobs if hospitals expect a sharp increase in uninsured patients as a result of a rollback of the Medicaid expansion, and employers may delay pay increases or new hires without the cost-saving incentives currently offered by the ACA.2

Those most at risk for harm in the event of a repeal are patients such as those in Dr Breathett’s study. In an accompanying editorial, Marvin A. Konstam, MD, chief physician executive at the CardioVascular Center at Tufts Medical Center and professor of medicine at Tufts University School of Medicine, Boston, Massachusetts, reiterated that Medicaid expansion is most likely the reason for the increased transplant listings observed in those findings.3 If it is rolled back, he told Cardiology Advisor, “will those individuals covered by Medicaid expansion be covered some other way? The answer, frankly, is probably not, and the most likely outcome is a rollback of the gains we have achieved in diminishing healthcare disparities.” He proposes that decision-making be redirected from the payer to provider and patient, and he makes several suggestions about what the ACA, or a similar law, should retain or do differently.


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Dr Konstam believes that the role of government subsidies to help cover care for the neediest citizens cannot be avoided, and that the mandate of basic healthcare coverage and the drive toward universal coverage and quality improvement should continue. “But there is much opportunity to debate the structure of the delivery system and the role of the private sector,” he added. His strong preference is to drive vertical integration by diminishing the “role of the middle man and give individuals and groups an opportunity to purchase coverage directly from an integrated network of providers.” Dr Konstam also recommends that competition based on quality and premium cost should be encouraged across these networks, and that states should be given “flexibility for innovation while still maintaining national standards for coverage and quality.”

Despite the inevitable challenges that will arise with ongoing revisions to healthcare policy, Dr Breathett says the focus on equitable care should continue. “As policy is changing with the change in government, we must advocate for the best interests of our patients, irrespective of politics,” she emphasized. “We as cardiologists and healthcare providers nationwide can unite in vocalizing the desire to put patients first in healthcare policy.”

Cardiologists can advocate for patients through organizations like the American College of Cardiology’s Political Action Committee, Dr Breathett suggests, and the new administration should tap bipartisan leaders in healthcare policy to evaluate access and outcomes, especially for minorities, women, and other vulnerable populations.

“Absence of universal coverage is the single biggest factor driving healthcare disparities in this country. These unethical disparities —socioeconomic, ethnic, and racial — are well documented and widespread,” said Dr Konstam. “Any replacement of the ACA that does not continue to drive universal coverage and does not work to diminish disparities would be a travesty.”

Disclosures: Drs Breathett, Allen, and Daugherty each disclosed grant funding from various organizations, as detailed online at JACC.

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References

  1. Buchmueller TC, Levinson ZM, Levy HG, Wolfe BL. Effect of the affordable care act on racial and ethnic disparities in health insurance coverage. Am J Public Health. 2016;106(8):1416-1421. doi: 10.2105/AJPH.2016.303155
  2. Obama BH. Repealing the ACA without a replacement — the risks to American health care. N Engl J Med. 2017;376(4):297-299. doi: 10.1056/NEJMp1616577
  3. Konstam MA. Affordable care: more than just an act. JACC Heart Fail. 2017;5(2):148-151. doi: 10.1016/j.jchf.2016.12.005
  4. Breathett K, Allen LA, Helmkamp L, et al. The Affordable Care Act Medicaid expansion correlated with increased heart transplant listings in African-Americans but not Hispanics or Caucasians. JACC Heart Fail. 2017;5(2):136-147. doi: 10.1016/j.jchf.2016.10.013
  5. Thibodeau JT, Rao MP, Gupta C, et al. Health insurance as a requirement to undergo cardiac transplantation: a national survey of transplant program practices. Transplant Proc. 2013;45(1):360-363. doi: 10.1016/j.transproceed.2012.05.074
  6. Pinney SP. Understanding and eliminating racial disparities in transplantation: still a ways to go. J Am Coll Cardiol. 2013;62(24):2316-2317. doi: 10.1016/j.jacc.2013.07.070
  7. Pollack CE, Armstrong K, Grande D. A view from the front line — physicians’ perspectives on ACA repeal [published online January 25, 2017]. N Engl J Med. doi: 10.1056/NEJMp1700144