Healthcare Reform: Is Bipartisan Legislation Possible?

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The effort to repeal and replace the ACA, which demanded much of our attention in 2017, is becoming a faint memory. Following failed GOP efforts to repeal and replace the ACA, the Administration has taken multiple steps to undermine the health insurance exchanges set up under the ACA. The latest bipartisan effort to continue providing support to the exchanges failed in September.

Into the policy vacuum following the failure of the bipartisan stabilization effort came a political nonstarter that brought with it more partisan bickering: “Medicare for All.” Meanwhile, healthcare costs continue to rise and the ACA’s flaws remain.

Senator John McCain and other members of Congress have called for Congress to pursue healthcare reform on a bipartisan basis, yet many struggle to imagine the possibility of bipartisan healthcare reform given the current bleak political backdrop.

Is bipartisan healthcare reform, or any bipartisan healthcare legislation, possible in today’s political environment? This article examines why previous legislation has failed and what it will take for future legislation to succeed.

Past Bipartisan Healthcare Legislation

Notwithstanding the current political environment, there are two recent examples of successful bipartisan healthcare legislation:

  • The 21st Century Cures Act, bipartisan legislation that passed in December 2016, focused on accelerating FDA approval of new drugs, among other programs, and enjoyed the support of 90 percent of the House and 94 percent of the Senate.
  • MACRA (Medicare Access and CHIP Reauthorization Act), including its healthcare payment reform provisions, was signed into law in April 2015 and enjoyed the support of 90 percent of the House and 92 percent of the Senate.

What conditions led to the passage of these acts? Are we so politically polarized now that the potential for bipartisan healthcare legislation is behind us, or can the conditions emerge again for bipartisan cooperation on healthcare issues? To help answer these questions, let’s examine why current healthcare reform efforts failed to see what lessons we might draw from them.

Why Repeal and Replace Failed

2017’s healthcare reform efforts failed, in large part, because they were rhetorical and politically motivated; they were designed to be politically useful during the 2016 election cycle and, following the elections, the GOP was under pressure to follow through on its campaign promises—a set of political circumstances that did not create true demand for the legislation.

The proposed legislation took on entitlements and long-standing features of our healthcare payment system. The bills introduced would have radically changed Medicaid reimbursement by, for the most part, converting payments to the states to a block grant program. Major entitlement program reform is tough in any political environment and usually requires building broad support over time.

Given the popularity of many ACA provisions, including the expanded insurance coverage (e.g., Medicaid expansion), the no pre-existing condition exclusion, and the ability to keep children on a parent’s policy until age 26, legislators were compelled to only partially repeal the ACA, which failed to satisfy those in the Republican party who wanted a complete repeal and replacement. Retaining these ACA provisions also undermined the stated intent of the legislation—If substantial features of the ACA were retained, and costs and the number of uninsured were projected to rise, then which constituencies were deemed to support the legislation? Not many, except for a narrow group of ideological opponents of the ACA.

Proposed legislation wasn’t motivated by practical considerations, such as cost control or what was best for patients, and it lacked substantial fact finding, hearings, and debate; therefore, proponents could not effectively build support or demand for the legislation.

Is there legislative will, or a political window, to launch bipartisan healthcare reform efforts that can take hold within the next year? Several opportunities exist.

Bipartisan Healthcare Legislation Opportunities

Paying for proposed tax reforms by targeting budget cuts and tax increases could move the lens to some of the largest federal government programs, including Medicare and Medicaid. Because the federal healthcare budget may need to be reduced to help pay for tax cuts, it could be practical to refocus on healthcare cost controls as a policy priority. Additional subject matter areas in healthcare, though few and far between, may also enjoy bipartisan agreement. The Bipartisan Policy Center recently summarized issues that could have bipartisan support:

  • Stabilizing the ACA.
  • Innovation waivers.
  • Expanding the use of HSAs.
  • Alternatives to the individual mandate to encourage health insurance enrollment.

This short list of “lowest common denominator” issues could grow if cost control and budget considerations take hold in Congress. Effective legislation in these areas depends on an understanding of what makes bipartisan reform successful.

What Makes Bipartisan Healthcare Reform Efforts Successful

What do recent successful bipartisan healthcare legislative efforts have in common? They tackled issues that didn’t include entitlement reform or ideologically based policy issues. The 21st Century Cures Act focused on funding clinical research, expediting the FDA drug approval process, and enhancing mental and behavioral health treatment programs, in addition to other broadly supported topical areas, such as promoting health information interoperability. MACRA focused on putting programs in place to reduce healthcare costs. Both acts focused on practical problems, the solutions to which had broad support.

Healthcare legislation that stands a chance of receiving bipartisan support will likely have one (or more) of the following features:

  1. Is driven by practical need rather than politics or ideology. The 2017 reform efforts demonstrated the weakness of politicking and ideology as motivating forces for healthcare legislation.
  2. Focuses on cost control and cost reduction in federal programs (e.g., helping to fund tax cuts, expanding military expenditures, or funding infrastructure projects).
  3. Targets low-hanging fruit in areas that are expected to save money (e.g., fixing MACRA, MIPS, and the ACA).
  4. Doesn’t involve creating new programs, for which it is harder to build support.
  5. Stabilizes the ACA. Sabotaging the ACA doesn’t serve a practical purpose—It doesn’t save the federal government money; in fact, it may cost more money. Plus, allowing the ACA to fail may undermine Congress’ credibility in its effort to enact programs and reforms in other areas.

Will Congress Meaningfully Respond to the Call for Bipartisan Solutions in Healthcare?

Congress’ focus is no longer principally on healthcare, having shifted to tax reform; however, with healthcare comprising 20 percent of the economy and more than 25 percent of federal government spending, healthcare may come back into focus again.

Stabilizing the ACA is likely to continue being a salient issue because the ACA’s instability and erosion, without a replacement, is embarrassing and damaging to the industry and patients, and results in higher costs. In the coming months, we will see if Congress meaningfully responds to the calls for bipartisan solutions in healthcare.

Additional Reading

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

  1. Three Affordable Care Act Questions Everyone Is Asking
  2. Why the 21st Century Cures Act Is Great News for Healthcare
  3. Is Value-Based Healthcare Here to Stay? Looking for Answers in New Policies
  4. Are Health Systems Ready for MACRA? Survey Reveals the Number One MACRA Concern and Varying Degrees of Readiness
  5. Preparing for MACRA: A Comprehensive FAQ for Physicians
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