A few weeks ago those of us who had experienced a few moments of unfounded hope based on positive comments that President Trump had made about the ACA had our hopes dashed when he announced that Representative Dr. Tom Price of the 6th Congressional District of Georgia would be the next Secretary of Health and Human Services. It is my assumption that after the Senate Finance Committee (Senate home of the ACA) grills Representative Price, he will be confirmed. The Senate’s HELP (Health, Education, Labor and Pensions) Committee has already given him a tough time, as noted in the New York Times article about how cabinet appointees are doing in the confirmation process:
Lastly, there was Mr. Trump’s pick to lead the Department of Health and Human Services, Tom Price, a representative from Georgia. Mr. Price made the preposterous claim that repealing the Affordable Care Act really wouldn’t hurt people as long as they had bare-bones insurance policies that paid for treatment only in catastrophic circumstances. He couldn’t offer any convincing defense of his proposals to strip hundreds of billions of dollars from the budgets of Medicare and Medicaid. In response to questions by Senator Elizabeth Warren, he said that spending on the programs was the “wrong metric” to judge them by and argued that lawmakers should instead focus on the “care of the patients.” Quality of care is certainly the most important standard, but why would drastic cuts to those programs magically result in people getting better medical treatment?
Mr. Price also could not explain why he and a broker he hired traded health care stocks when he was proposing and voting for legislation that would affect those companies. He refused to see that even if he didn’t violate insider-trading laws, his investments represented a huge conflict of interest.
Despite his views and despite his financial entanglements, I assume that the Republican majority will confirm him. Then what? You have probably read a lot of conflicting articles about what might happen. The President says the result will be universal coverage that will make everyone very happy. The CBO and others who have a more granular understanding of the law and the insurance business are predicting that tens of millions will lose coverage. As the Stat article describes:
The Obamacare repeal effort is just getting underway and already the political wordplay is dizzying. On the GOP side, the rhetoric has gone from “repeal and replace” to “insurance for everybody” to “repair and rebuild.” Meanwhile, Democrats continually warn that the Republicans are trying to “rip apart our health care system.”
House Republicans seem to understand that repealing the ACA has the danger of negative political consequences. The public is beginning to understand that they should learn a little more than they were offered during the election when healthcare was hardly discussed. Perhaps you have heard about the woman who voted for Trump because she hated Obamacare, but she was very upset to hear that he was going to repeal the ACA and cost her the benefit of having her son on her insurance policy.
Representative Greg Walden of Oregon is the Chairman of the Energy and Commerce Committee of Congress where much of the action will occur. He has long been an opponent of the ACA and is credited with the creation of the slogan “repair and rebuild” to replace “repeal and replace”. Walden has led the efforts to get more Republicans elected to Congress over the last two elections and just maybe he has the political experience to give him some insight into the downside of rapid repeal. We will see.
What worries me most is the difference between “rhetoric and reality”. Tom Price says that as HHS Secretary he will make sure that no one has “the rug pulled out from under their healthcare” and President Trump promises “something better.” But nowhere is there more detail.
The Washington Post seems skeptical of Trump’s assertion and suggests that the job will be harder than he realizes:
Trump declined to reveal specifics in the telephone interview late Saturday with The Washington Post, but any proposals from the incoming president would almost certainly dominate the Republican effort to overhaul federal health policy as he prepares to work with his party’s congressional majorities.
Trump’s plan is likely to face questions from the right, after years of GOP opposition to further expansion of government involvement in the health-care system, and from those on the left, who see his ideas as disruptive to changes brought by the Affordable Care Act that have extended coverage to tens of millions of Americans.
Perhaps the most important point that the Stat article makes is the ambiguity in the way Republicans use the term “universal coverage”. When I use the term I mean that everyone has coverage to high quality care that includes chronic disease and preventative health benefits across the board as recommended by the IOM in the ten determinates of a better system of care as described in Crossing the Quality Chasm. When a Republican politician uses the term it means that everyone could have coverage of some kind at least for catastrophic conditions. The New York Times points out that using the term “Universal Access” in a disingenuous way that does not take into considerations the realities of how the insurance market works could lead to big problems for consumers. It’s a wink-wink kind of thing as implied by a quote in the article:
“Our goal here is to make sure that everybody can buy coverage or find coverage if they choose to,” a House leadership aide told journalists on the condition of anonymity at a health care briefing organized by Republican leaders.
Don Berwick and the Stat article point out that there is more to the ACA than the insurance that it provides to those who have gained coverage through it. In a very succinct article in the Huffington Post, which you must read, Berwick describes the complexity of American healthcare better than I have ever seen it presented. He writes:
To get your bearings, keep in mind the main categories of health insurance coverage in the U.S. There are five: Medicare (the federal “single payer” program that covers roughly 58 million people over 65 years of age), Medicaid (the federal-state matching-funds partnership that covers 68 million children, people of very low income, people with disabilities, and people in nursing homes who have spent down the bulk of their assets), employer-based insurance for 156 million, the non-group market (about 22 million people who have to find insurance on their own), and the Children’s Health Insurance Program (which is another federal-state matching funds program that covers about 8 million children and pregnant women in families of limited income).
Another 18 million are covered by the military or Veteran’s Administration. And 28 million people in our country still have no health insurance at all.
The ACA, and its repeal, affects every one of those segments, but differently.
He goes on to categorize how repeal of the ACA hurts Medicare because it has lowered the cost of care by its emphasis on quality and value based reimbursement in a movement away from fee for service. The facts are important:
Medicare spending per person went up 7.4 percent per year in the ten years before the ACA, and 1.4 percent per year since the ACA….The result for Medicare beneficiaries will be backsliding: higher costs and worse care.
Next up Medicaid:
Their “replace” proposal, still behind curtains, is probably going to try to change the way all of Medicaid is funded, from the matching program in place since 1965, to “block grants” to states or “per capita” limits, under which the federal government would simply give a fixed amount of money to each state. The intent is to reduce federal Medicaid funding. The caps would be set at levels below what Medicaid is expected to cost, and disparities in coverage among states would be locked in. States would end up holding the bag as, say, needs changed or a recession occurred. Over the next decade, federal Medicaid payments would fall by 1 trillion dollars, and 14.5 million people would lose coverage by 2021.
Ouch! But I am okay if I have commercial insurance through my employer, right?
Don sees it differently:
Repeal of the ACA hurts employer-based insurance. With tens of millions of people no longer insured via Medicaid expansion and subsidies, hospitals and doctors would find themselves back in the bad-old-days of uncompensated care and inadequate pools to support their free care. There will be nowhere else to turn for resources than to higher premiums for people who do have insurance. The new administration says it would keep many of the popular ACA protections for insured people, such as the abolishing of lifetime limits on coverage and forbidding insurers from denying coverage to people with preexisting conditions. But the math doesn’t work. There is no way to support a viable insurance market with those requirements absent the elements of the ACA that the Republicans want to end ― including the individual mandate. Bottom line: if you think your employer-based premiums went up too much under the ACA, just wait until it’s gone to see what the ACA was actually protecting you from.
Most people, including many in healthcare, have no idea what “the non group market” means. Don explains:
Repeal will hurt the non-group market in many ways most of all. Individuals who want insurance but are not in large groups are not attractive customers for insurers; many tend to have worse health and a lot of them are far from wealthy. That’s one reason why the ACA set up the so-called “exchanges,” marketplaces with federal subsidies for people whose incomes are too high for Medicaid eligibility but too low to afford usual insurance on their own. The exchanges did have problems; mainly, their enrollees have turned out to have higher risks than predicted and therefore some individual and small group premiums soared. That is all fixable – California did it, and so did Alaska. But, with repeal of the subsidies, there will be nothing left to fix; the exchanges will implode, leaving over 8 million individuals high and dry.
Most Republicans love children and would probably swear that they would do nothing to deny needed medical services to insure the health of the next generation. Much pain is created in the world by not paying attention to details. The average Trump voter probably did not realize that the care of children would suffer with “repeal and replace”. Their concern was perhaps directed at those too lazy to take care of themselves. Don has news for them:
And, finally, CHIP. This highly successful program has provided coverage for millions of children and pregnant women who have no affordable alternative. It has to be reauthorized later this year, and some Republicans propose to end it.
We all have much to lose whether we realize it or not. You can do the analysis from the point of view of social justice or cold hard cash, but as Don concludes:
Add it all up, and, according to the Urban Institute in Washington, ACA repeal will throw 30 million Americans off of health insurance. And it’s not just the poor who will suffer. Repeal will harm almost every category of insured population in this nation. It will unleash unprecedented increases in insurance rates and worsen benefits for most people with insurance. Repealing the ACA without a clear, cogent, politically viable, and effective alternative – a “replace” that works – is not responsible.
I would suggest that those working on the bill begin by reading the paper in JAMA that former President Obama published last year. If such a bill were passed, we would be on our way toward
Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time…in settings that support caregiver wellness
