Learning from Variation in ACA Implementation

Political scientists, economists, and other social scientists frequently exploit variation in the implementation and timing of policy initiatives in order to estimate impact and effectiveness. The Affordable Care Act (ACA) creates abundant opportunities for these types of variation studies and natural experiments that can help us learn which implementation strategies work best, for which population groups, and under what conditions.

Numerous ACA provisions give states, local governments, health care systems, and even individual providers broad discretion in deciding what to do under ACA and when to do it. Beyond the high-visibility state decisions concerning Medicaid expansions and health insurance exchange operations, states are making hundreds of other implementation decisions about strategies like insurance outreach and enrollment, provider network adequacy, multi-payer payment models, and initiatives to expand and integrate medical, public health, and social services delivery systems to improve population-wide health status. Hospitals and physicians get to decide when and how to try their luck at ACA-supported accountable care organizations (ACOs), patient-centered medical homes (PCMHs), and various forms of bundled-payment and shared-savings models. Insurers and employers are choosing whether and how to incorporate incentives for quality improvement and wellness into their health benefits designs. Public health and community-based organizations get to decide whether and how to compete for funding to implement policy, environmental, and system (PES) changes that promote health and prevent disease and injury with support from the ACA’s Prevention and Public Health Fund. Variation due to public-private discretion, competition and entrepreneurship abound within the ACA.

How do we harvest the potential knowledge and learning from this large-scale implementation variation? A meeting this week at the Brookings Institution in Washington DC focused on developing some key research strategies. One conclusion reached early on in the meeting: it is possible to capitalize on the fact that many, many research institutions have studies underway regarding ACA implementation and impact. RAND’s Health Reform Opinion Survey and COMPARE microsimulation model, the Urban Institute’s Health Reform Monitoring Survey, the University of Chicago’s ACA Scholar Practitioner Research Network, the Princeton University/RWJF State Health Reform Assistance Network, Georgetown’s Center on Health Insurance Reforms, Kaiser Family Foundation’s Health Reform Initiative, and many other fellow travelers have big studies underway regarding key elements of ACA. (This includes our PHSSR Center’s own studies of ACA’s effects on the U.S. public health system). These many individual studies create opportunities for harmonization, triangulation, data linkage and pooled analyses, meta-analyses and research synthesis.

What’s missing from the many “big data” ACA studies are clear pictures of what’s happening on the ground in individual states and communities – an ability to characterize the patterns of variation in implementation at more granular scales, and to determine how these patterns influence health care delivery and outcomes. The research community has yet to provide a clear understanding of how and why ACA implementation strategies vary across the U.S., and how these various strategies play out in different political, institutional, socioeconomic and cultural contexts.

To fully exploit the research opportunities presented by ACA implementation variation, researchers require the ability to be many places at the same time and observe what is happening on the ground in a variety of communities and practice settings. Researchers need the stamina and staying power to observe implementation processes continuously over time. And researchers need the versatility to employ mixed-method research approaches that productively combine (1) large amounts of qualitative data on implementation strategies collected from multiple perspectives and settings with (2) the array of large quantitative data sources that offer measures of provider and consumer behaviors, service delivery patterns, and related health and economic outcomes.

This is where the Brookings Institution’s Engelberg Center for Health Care Reform and their partners at the Rockefeller Institute of Government at SUNY and the Fels Institute of Government at the University of Pennsylvania come into play. Over the past year, scholars at these institutions have convened a multidisciplinary network of researchers across the U.S. who are well-positioned geographically and institutionally to observe ACA implementation strategies at granular levels in some 36 states. The researchers that comprise the ACA Implementation Research Network have access to multiple ACA decision-makers and key informants, multiple sources of secondary data, and a variety of supporting documents and records relevant to ACA implementation at state and local levels. Already, this network has completed a series of baseline studies of ACA implementation in a broad cross-section of states (for example see our report on ACA in Kentucky and similar reports for other states).

After demonstrating proof of concept through these baseline studies in individual states, the ACA Implementation Research Network is now embarking on a series of larger-scale, cross-cutting topics that involve collection and analysis of standardized data on ACA implementation across a large number of states. This first wave of cross-cutting studies target topics such as: (1) state information technology strategies and capacities to support ACA implementation; (2) consumer support and outreach strategies for insurance enrollment; (3) provider network composition among insurers participating in the state exchanges; (4) implementation strategies used in “oppositional states” where policy leaders oppose the ACA; and (5) state strategies for reforming health care and public health delivery systems. I hope to play a leading role in this last cross-cutting study, together with other colleagues in the PHSSR enterprise. Specifically, we hope to leverage studies that we already have underway concerning public health delivery system reform, and to leverage the strength of our public health practice-based research networks (PBRNs) across the U.S.

The ACA Implementation Research Network is strongly committed to engaging knowledge users in the design and implementation of its ACA research, and to disseminating findings rapidly and continuously to decision-makers in policy and practice settings. We are excited to be a part of this collaborative experiment in large-scale policy implementation field research, and we believe it will become a valuable source of knowledge and learning over time. Fellow travelers in public health economics and delivery system research will want to keep close tabs the progress of this new effort.

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