In a little piece of legislation known as the Affordable Care Act, preventive services are mandated to be covered with no out-of-pocket expense to consumers. According to the Healthcare.gov website, approved insurance plans must cover a “list of preventive services for children without charging a copayment or coinsurance.” Number 18 on that preventive care list is: childhood immunizations for children from birth to age 18, acknowledging regional variation in the standard recommendation schedule. After all, vaccinations are the cornerstone public health achievement of the last century and have saved countless pediatric lives.
As the White House continues to push for a revised Republican proposal to replace the Affordable Care Act (ACA), one thing is for certain, many of the sickest Americans will continue to suffer as they are denied medications and other treatments under current health insurance strategies to save costs.
Both the ACA, and the recently proposed MacArthur Amendment, do not address a well-established practice of health insurers’ use of restrictive prior authorization requirements to deny or delay coverage of medications and treatments to seriously ill patients. In my own practice caring for cancer patients and those with terminal conditions, I have witnessed the additional suffering caused by denying these patients timely access to medications for pain.
A prior authorization is essentially a check run by insurance companies or other third party payers before approving certain medications, treatments, or procedures for an individual patient. Insurance companies justify this practice as a means to save costs to consumers by preventing unnecessary procedures from being covered, or requiring generic drugs to be used instead of brand-name, more expensive alternatives.
Barely one month after a stinging and stunning legislative defeat, President Donald Trump has committed to revising the AHCA and potentially resubmitting it for Congressional approval.
In addition to Democrats and widespread popular opinion against ACA repeal, the AHCA may face another obstacle – international law.
This week the Washington Post’s Dana Milbank reported that the United Nations Office of the High Commission on Human Rights forwarded a four-page letter to the Acting Secretary of State, Thomas A. Shannon, to express the Commission’s “serious concern” that the US was in danger of violating its obligations under international law if the U.S. ratified legislation repealing the ACA.
The letter authored by Dainius Puras, a Lithuanian with the somewhat remarkable title of UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, argues that repealing core elements of the ACA would negatively impact almost 30 million Americans’ right to the “highest attainable standards of physical and mental health”, particularly those in moderate and low income brackets and those suffering from poverty or social exclusion.
With the failure of the Republican’s American Health Care Act (AHCA), what’s next? Congressional Republicans face the ugly choice of admitting defeat and funding the Affordable Care Act (ACA), including the cost-sharing reductions (CSRs) that they have tied up in federal court, de-funding the ACA and likely being blamed for its demise, or compromising with Democrats to improve it. In all likelihood, the next set of moves will focus on avoiding/shifting blame for the imminent crisis of health plan withdrawals that failure to fund CSRs would precipitate.
But the long-term problems with the ACA should be addressed: How to sustain health plan competition? How to simplify a nearly incomprehensible medical financing scheme? How to cover more of the uninsured? How to win enough moderate Republican support to de-escalate partisan wars over the ACA? Sooner or later, Congress needs to consider serious compromise proposals for improving the ACA.
So, what might they consider?
Were a bargain on improving the ACA to be struck, Democrats would insist that it ensure full federal funding and maintain goals related to covering most Americans. Taxes will be the “sticking point” for many Republicans, but not all: Senators Cassidy & Collins’ Patient Freedom Act (PFA) retains 95% of current funding.) On the other hand, the price of support from moderate Republicans probably includes making substantial changes that borrow heavily from the best ideas in the AHCA and the PFA. The approach proposed below does both.
I propose three goals for a bipartisan effort to “reform and improve” the ACA:
On March 23, 2010, Congress passed the “Patient Protection and Affordable Care Act”. It soon became known as the “Affordable Care Act aka ACA” before being labeled “Obamacare”.
Its aims were two: to reduce costs and cover everyone. In the 79 months since passage, it remains arguably the most divisive public policy platform since FDR’s New Deal in the ‘30s and Lyndon Johnson’s Great Society in the 60s. Per Kaiser Family Foundation’s Tracking polls since its passage, the public’s view about the ACA remains split: half think it’s an overreach by the federal government that has resulted in sky-rocketing health insurance premiums across the board, and the other half believe expansion of insurance coverage for 25 million justifies the effort. Each side cherry-picks elements of the law they like and decry parts they despise.
But all concede the law has not addressed affordability as originally intended. News about insurance premium spikes, has dogged the ACA since its passage lending to critics’ conclusions that the law was fundamentally flawed and had to go.
In 2009, I facilitated several meetings for the White House Office of Health Reform seeking industry input into reform legislation.
I’ll dive right in, with the stipulation that this blog is initial reaction in a very fluid, unprecedented and soon-to-be even-more-intense political environment. Fasten your seat belts!
The ACA. Replace is the critical word in “repeal and replace.” Consensus is already emerging that Trump and the Republicans will indeed repeal the ACA in early 2017, via the reconciliation process Congress used earlier this year. That resulted in the Senate’s first an only full ACA repeal vote. Obama vetoed the bill, of course. But Republicans demonstrated the do-ability of the reconciliation process. Lacking 60 votes in the Senate, they’ll very likely try repeal again that way.Continue reading…
As a Democrat, I can only hope this is a Dewey defeats Truman moment, but at 2.00am ET on Nov 9, President Trump with a Republican House and a open Supreme Court seat seems to be our new reality. For the health care establishment, this is a bombshell. It’s been easy for Congressional Republicans to vote to repeal the ACA when they knew Obama would veto it. But what happens next when Trump is happy to sign the “repeal”?
It’s hard to figure out what’s there in terms of putting together to “replace” either in the Congressional Republicans or in what passes for policy in what passes for the Trump camp. As Margalit Gur-Aire said on THCB recently other than one speech with some stale talking points about block grants for Medicaid and selling insurance across state lines, Trump seems to have no ideas about health care. (To be fair he doesn’t seem to have any ideas about anything, or he claims they’re a secret).
Then we have the issue of his relationship with Congress. Now he’s President he may declare a truce, but then again he might decide to tweet into oblivion Paul Ryan and the many others who wouldn’t support him. And he might of course self-immolate as he tries to manage his business, his relationship with Russia and his soon to be launched TV network–while actually having to be President.
But if he’s going to end Obamacare, Trump is going to have to worry about two things. First, he has said that he wants to repeal it but is going to make sure everyone can buy health insurance, even if they have preconditions. When the middle aged white working class who voted for Trump discover that their Medicaid and their health insurance goes away, and that insurers wont sell them insurance if they’re not a good risk, they might be unhappy.
Second, the other people who are going to be unhappy are the health care industry stakeholders. Health care is a series of complex legislative and market interactions. As a consequence of the ACA, most health insurers, providers and even pharma or device companies have made huge changes to their business strategy. Those business strategies and investment are now six years old. Like Wall Street and corporate America, Trump is going to make the health care establishment deeply uncomfortable. The question is, once big pharma, insurers and providers lean on the Administration, will anything actually change, or will we see the route towards value-based care continue?
Not only that, but the sea-change that is just starting in the shift from FFS to value-based payments from Medicare & CMS is underway because the country can’t afford continued health care cost growth. That remains the same. Eventually that reality will impinge even on a Trump administration.
So what happens next? Well it’s amateur hour and we’ve all failed to predict it thus far, so it’ll be tough to do it now. But health care will be a sideshow.
Oh, and time to repeal the frigging electoral college.
ACA permits people to sign up even if they are already sick. Real insurance cannot work that way.
Imagine an Accountable Fire Insurance Act that required insurers to sell you fire insurance after your home had burned. Homeowner insurance rates would skyrocket. Anyone who carefully read the ACA would see that coming.
The big insurers knew this would happen but played along in the beginning to avoid attracting political fire.
When 75% of Americans get a taxpayer subsidy under ACA, it isn’t really insurance but more of an income redistribution mechanism…for better for worse.
There it is, 97 words.
“Value” is the most important concept in healthcare today. But it’s problematic.
Futurists say our system is transitioning from volume to value. Device and drug manufacturers tout the value of their products. It even found its way into Wednesday night’s Presidential debate when frontrunner Hillary Clinton answered Chris Wallace’s query Medicare’s long-term viability with the following reply: “We’ve got to get costs down, increase value, emphasize wellness. I have a plan for doing that.”
Value is defined as “a fair exchange in return for a thing” (Dictionary.com). Per Webster’s, it is a “fair return in goods, services, or money for something exchanged; worth in money; usefulness, or importance in comparison with something else.” In essence, it is the relationship between what something costs and the benefits that accrue to its purchaser. Transactions between buyers and sellers based on the purchaser’s deduction of what something costs and the benefits derived are the basis for value-based economics. They’re aided by rating services like Consumer Reports that provide useful methods for making selections: the current issue covers SUVs, coffee makers, nut butters and gas/electric ranges. Very straightforward. Side by side.
One of the main goals of the Affordable Care Act (ACA), perhaps second only to improving access, was to improve the quality of care in our health system. Now several years out, we are at a point where we can ask some difficult questions as they relate to value and equity. Did the ACA improve quality of care in the ways it intended to? Did it do so for some people, or hospitals, more than others?
How did the ACA Attempt to Improve Quality?
Three particular programs created by the ACA are worthy to note in this regard. The Hospital Acquired Condition Reduction Program (HACRP) took effect on October 1, 2014 and was created to penalize hospitals scoring in the worst quartile for rates of hospital-acquired conditions outlined by the CMS. The Hospital Readmissions Reduction Program (HRRP), which began for patients discharged on October 1, 2012, required CMS to reduce payments to short-term, acute-care hospitals for readmissions within 30 days for specific conditions, including acute myocardial infarction, pneumonia, and heart failure. The Medicare Hospital Value-Based Purchasing Program (HVBP) started in FY2013, was built to improve quality of care for Medicare patients by rewarding acute-care hospitals with incentive payments for improvements on a number of established quality measures related to clinical processes and outcomes, efficiency, safety, and patient experience.