Transforming the System of Care for Older Adults: The Affordable Care Act, Five Years Later

Doctor talking to mature male patient in hospital room
Doctor talking to mature male patient in hospital room

The Affordable Care Act (ACA) has endured its share of controversy, facing both legal challenges and implementation difficulties. Even with these struggles, the ACA has created landmark improvements to our health care delivery system. Before the ACA, many Americans lacked access to affordable health insurance; today, over 16 million previously uninsured Americans have coverage. Similar parallels can be drawn for older Americans. Over the last several decades, the nation's health care delivery and long-term care systems have become even more fragmented -- leading to confusion, poor health outcomes and higher costs of care. Contained in the ACA are important provisions focused on the needs of vulnerable adults that start to address these challenges. Whether through expanding proven models or exploring new approaches, these ACA opportunities all seek to better coordinate health and long-term care services. While much work remains to create a fully coordinated, person-centered system, the last five years have produced real progress toward this goal at both the federal and state levels.

Recently, The SCAN Foundation released a policy brief looking at eight specific areas in the ACA that created new opportunities to improve care coordination as well as "rebalance" the long-term services and supports (LTSS) system. The goal was to put more emphasis and funding on services that help older people remain healthy in their homes and communities. Below are a few areas that seek to better link the medical and LTSS systems:

  • Health Homes - Medicaid "Health Homes" seek to create strong, community-based care coordination and better integration of community-based services with medical care. Currently, 16 states have approved health home models with another 26 planning to start or expand their programs over the course of this year.

  • Dual Eligible Integration Pilots - Older adults in 11 states, eligible for both Medicare and Medicaid, are starting to see better coordination of services and funding through pilot projects.
  • Expanded Access to Home and Community-Based Services - States used a number of policy tools to increase LTSS access in the community, allowing older adults to achieve their daily living goals in the setting of their choice. Programs such as the Community First Choice Option allow states to use Medicaid dollars to provide home and community-based attendant services, as well as fund back-up systems, training, and services for transitioning from an institution to the community.
  • For older adults, the ACA has fostered delivery system innovation at the state and regional levels. Most of these new models, however, are in the early stages of implementation. Judging the full success of these programs -- better, more person-centered care that uses resources more efficiently -- will require both more time and thoughtful evaluation. It is clear that the law has been a catalyst for moving toward a more coordinated system of care through federal programs run by the Centers for Medicare and Medicaid Services, state-delivered programs such as Medicaid, as well as private industry with new mechanisms to innovate. Building on these early successes, we must continue improving care delivery for older adults, particularly those with high health care needs and daily living challenges. Potential next steps include:

    • Expand the current health assessment process beyond medical problems to include functional needs as the basis for a single comprehensive plan of care;

  • Foster robust quality improvement evaluations at the state and local levels to help understand what is working well and where there are course corrections needed; and
  • Develop quality benchmarks for measuring outcomes that put the older person's ideas of success at the center, instead of focusing on the health system's perspective of quality.
  • Since becoming law, the ACA has substantially decreased the number of uninsured and started transforming the way health care and LTSS are delivered. However, one of the other lasting legacies from the ACA may be how it launched the widespread adoption of a more person-centered system of care for older adults. While portions of the ACA continue to be debated, using the tools within the ACA to drive innovation in the public and private sector at the community, state and federal levels should be a priority for all who care about better care at lower costs. We must ensure this transformative work drives us toward a more efficient, effective, outcomes-focused health care system that is better prepared to help all Americans age with dignity and independence.