Three Affordable Care Act Questions Everyone in Healthcare Is Asking

It has been a wild ride in healthcare policy this year, with many surprises, advances, and retreats. But one thing that has been well established is that President Trump’s and the Republican Party’s campaign rhetoric did not match the reality of healthcare policy reform.

Let’s look at the rallying cry: “Repeal and replace Obamacare.” Even the latest version of the bill that finally passed in the House is far from a complete repeal and replacement of the Affordable Care Act (ACA). And there are long odds that many of its provisions will survive in the Senate version of the bill.

This experience has reminded us, again, how hard it is to roll back popular government entitlement programs. The tens of millions of Americans who stand to lose health insurance coverage and other popular protections that they had gained under the ACA, such as no lifetime caps and no pre-existing conditions exclusions, are helping to remind their elected representatives of this fact.

Make no mistake—the bill advanced by the House includes some very significant changes to healthcare policy and coverage, chief among them:

  • Elimination of the “Individual Mandate.”
  • Massive cuts to Medicaid.
  • Shifting Medicaid management and financial accountability to the states.
  • Elimination of a number of the taxes that fund the ACA’s programs.

However, the fact remains: The House bill is a significant retreat from the complete repeal and replace initially advocated by the Freedom Caucus and others. The ACA’s cost control provisions were not addressed at all, including the CMS Innovation Center and its demonstration programs, and the Medicare Shared Savings Program (MSSP). To address the repeal of the popular provision requiring insurers to cover patients with pre-existing conditions, the bill included the formation and funding of high-risk pools.

The Senate will likely put forward its own plan, and most observers agree that the reconciliation process will be a long and challenging one. What bill (if any) will result from that process is anyone’s guess. So where does that leave healthcare organizations trying to plot a path forward? This article answers three key questions to help health systems head in the right direction.

Three Affordable Care Act Questions Everyone in Healthcare Is Asking

When it comes to healthcare policy, health systems need answers to three key questions:

  1. What will the final bill look like?
  2. How do I plan for the changes?
  3. What should happen next to fix the problems with the ACA?

Maybe a better question to ask at this point is, “How much does it really matter?” I am not suggesting that the effects of a significant healthcare policy reform bill do not have a deep and broad impact in the long term. What I am suggesting is that it may provide a helpful perspective to step back from the battlefield we have been observing and take a harder look at the aspects of our business and organizations that are truly likely to be impacted by the reform.

We can’t predict what reform is coming. But we do know that a complete repeal and replacement of the ACA is highly unlikely. We also know that there will be a transition period of several years for the major changes enacted by any reform legislation, so there will be time to respond and plan. We also know that it is very likely that cost control and quality programs will continue in their current form, at least for the foreseeable future. In fact, from a pure cost-benefit standpoint, it probably makes a lot more sense to focus on adjusting and repairing those programs than reforming the government’s healthcare coverage programs.

The Affordable Care Act Debate: Coverage Reform Vs. Cost Controls

Getting rid of the whole ball of wax—repealing Obamacare—was rhetorically very appealing on the campaign trail. And it worked! Trump is president, and the Republicans control Congress, likely due in significant part to the way the base was rallied against a “big government” entitlement program. But broad-based coverage reform might be the wrong policy approach, according to many healthcare policy thinkers on both sides of the aisle.

Coverage reform gets into the territory of entitlements (taking away entitlements), and the polarizing ideological issues of the role of government in the healthcare system. On the other hand, focusing on cost controls rather than coverage reform can be more effective without the polarizing political issues.

The key problem with the ACA is that it did not accomplish enough in controlling healthcare costs. And when healthcare costs run away, this causes problems all the way across the field of play (e.g., it is harder to have affordable coverage plans, and difficult choices must be made about the level of benefits). Achieving real and sustainable cost controls could therefore solve many of the problems that coverage reform is trying to address, but more efficiently and effectively.

It is not a coincidence that value-based care programs, including the MSSP and the bundled payments initiative, have, so far, survived the partisan swiping. Some of these programs are starting to see success, and there is very little for both blue and red politicians not to like about healthcare cost savings. Both parties, for example, supported the Medicare Access and CHIP Reauthorization Act (MACRA) and its cost control programs.

Further, cost control would carry far fewer political risks for the Republicans. The party is already under fire for the House bill’s rollback of the popular coverage and patient protections of the ACA. If there is a backlash, it could be compounded if Trumpcare also fails to achieve any meaningful cost controls.

Amidst Affordable Care Act Uncertainty, Focus on Patients and Delivering Quality Healthcare

While cost control efforts would be the more middle-of-the-road, sensible healthcare policy approach, our current political season is not about moderation or bipartisan policy efforts. It is largely driven by ideology, and healthcare coverage reform is Exhibit A in the ideological battles about the role of government policy and participation in healthcare.

A long-term strategic approach would counsel not getting pulled into the continuing political turmoil but to be guided by the longstanding mission and principles of our health systems and providing quality healthcare. The battles will continue in Washington with or without us, so we need to prioritize serving our patients.

Additional Reading

Would you like to learn more about this topic? Here are some articles we suggest:

  1. Is Value-Based Healthcare Here to Stay? Looking for Answers in New Policies
  2. Why the 21st Century Cures Act Is Great News for Healthcare
  3. The Key to Transitioning from Fee-for-Service to Value-Based Reimbursement
  4. Preparing for Changes to Medicare Reimbursement—The Latest CMS Proposed Measures
  5. Rising Healthcare Costs: Why We Have to Change
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