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Storm rising! The Obamacare exchanges will catalyze change: why physicians need to pay attention to the weather
  1. Joshua A Hirsch1,
  2. Thabele Leslie-Mazwi2,
  3. Gregory N Nicola3,
  4. James Milburn4,
  5. Claudia Kirsch5,
  6. David A Rosman6,
  7. Chris Gilligan7,
  8. Laxmaiah Manchikanti8,9
  1. 1 Massachusetts General Hospital, NeuroInterventional Radiology, Boston, Massachusetts, USA
  2. 2 Massachusetts General Hospital, Neurosurgery, Boston, Massachusetts, USA
  3. 3 Hackensack Radiology Group, River Edge, New Jersey, USA
  4. 4 Ochsner Medical System, Radiology, New Orleans, Louisiana, USA
  5. 5 Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Radiology, Hempstead, New York, USA
  6. 6 Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts, USA
  7. 7 Brigham & Women’s Hospital, Department of Anesthesiology, Perioperative and Pain Medicine, Boston, Massachusetts, USA
  8. 8 Pain Management Center of Paducah, Paducah, Kentucky, USA
  9. 9 University of Louisville, Department of Anesthesiology and Perioperative Medicine, Louisville, Kentucky, USA
  1. Correspondence to Dr Joshua A Hirsch, Massachusetts General Hospital, NeuroEndovascular Program, Boston MA 02114, USA; hirsch{at}

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The Patient Protection and Affordable Care Act (ACA) of 2010, commonly known as Obamacare has had a large effect on healthcare delivery to millions of Americans.1–3 There are many elements of the ACA that could impact NeuroInterventionalists. One prominent example is the formation of independent boards with the power to unilaterally modify physician payment structures and use comparative effectiveness research to change medicine and healthcare delivery.4 5

Additionally, the ACA established a formal framework for considering the transition from ‘volume to value-based’ healthcare through the creation of the Innovation Center.6 Among the seven broad approaches for achieving this migration, two methodologies were of particular relevance to NeuroInterventionalists; the Bundled Payment for Care Improvement Initiative and Accountable Care Organizations, with both approaches remaining active elements into the present day.7–11 Prior to passage of the ACA, the problem of Americans lacking adequate health insurance coverage (absent or insufficient) grew worse each year. In 2010, 55.3% of Americans were covered by employer-based insurance.12 The elderly and poor, as well as some additional vulnerable groups, were already covered by Medicare and Medicaid (14.5% and 15.9% 13 of the population respectively).13 Additional programs, such as the Veterans Health Administration, provided coverage to a small proportion of the population. Shockingly, by 2010, almost 50 million Americans had no form of medical insurance. The drafters of the ACA legislation considered expanding coverage to be mission-critical. Ultimately, they decided on two main strategies to achieve that goal.

The first strategy was Medicaid expansion. By increasing the number of patients eligible to receive Medicaid, many more people would obtain insurance coverage. To enable this expansion, the ACA loosened the criteria required for becoming a Medicaid beneficiary and millions of additional patients signed up for the program. Nonetheless, a large cohort of patients remained uninsured …

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