Consequences of the Affordable Care Act for Sick Newborns

* Abbreviations: ACA — : Affordable Care Act ACO — : Accountable Care Organization In the United States, half a million infants annually require care in a NICU, which is often complex and prolonged. To achieve the best possible clinical outcomes, the needs and resources for these fragile infants must be matched appropriately. Few arenas of modern medicine have been more efficacious than regionalized perinatal and neonatal intensive care. Regionalized health care has been described as a coordinated system of care “to improve patient outcomes by directing patients to facilities with optimal capabilities for a given type of illness or injury.”1 The most complex infants are ideally born and cared for at regional high-risk perinatal centers, and large-scale regional referral networks have been successful in ensuring access to these facilities for all women and infants in need.2,3 However, driven by lucrative reimbursement for high-risk obstetric and neonatal care, the last 2 decades have witnessed an erosion of regionalized referral systems.4 In 2013, major parts of the Affordable Care Act (ACA) went into effect. The goals of the ACA mirror the Institute of Healthcare Improvement’s Triple Aim of better care experience, lower cost, and improved population health.5 The changes in provider incentives and regulations will provide concrete benefits to women and infants, including better access to health insurance through Medicaid expansion and health exchanges, more comprehensive insurance coverage for pregnant women and newborns, and potentially less fragmented, better coordinated, and higher value care through Accountable Care Organizations (ACOs) and other capitated arrangements. The ACA will exert some of its influence on perinatal care delivery by realigning financial incentives, which could destabilize perinatal regional referral systems, unless carefully monitored and managed. The ACA is not primarily concerned with high-risk infants but several of its provisions could have potentially adverse effects … Address correspondence to Jochen Profit, MD, MPH, Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine, MSOB Room x115, 1265 Welch Rd, Stanford, CA 94305. E-mail: profit{at}stanford.edu