Special Report—8 ways to fix the Affordable Care Act

psycho097Gienna Shaw back in August of 2017 stated that even former President Barack Obama knew that his signature healthcare reform law, the Affordable Care Act, had problems.

Democrats can fix the Affordable Care Act, so how come they are now touting Medicare for All?

So, the Mueller report is out but the fighting will go on with the Psychos of both parties will continue to destroy our system and continue to hate and refuse to be civil and do what we the voters paid them to do. I don’t know about any of you out there on the Internet, but I am really tired of the lack of process improvement, especially since I just published a book on process improvement. I should probably go down to D.C. and give every member of the House and the Senate a copy. But back to our topic of discussion the fixes for the Affordable Care Act!

Jon Kingsdale in his review last December noted that Federal District Judge Reed O’Connor’s determination last Friday overturning the entire Affordable Care Act won’t actually affect much — unless it is upheld at the Supreme Court, probably not until 2020 — but it ought to spark a substantive legislative response from House Democrats.

President Trump was quick to gloat and to invite Democrats to negotiate a replacement. With more and more Democrats dreaming of “Medicare-for-all” and the remaining Republicans in Congress after 2018 representing the far right, the prospects for “negotiating” a replacement are nil. This is simply an opportunity to blame Democrats for failing to “step up” and negotiate their own defeat.

Which is one reason that newly empowered House Democrats should use O’Connor’s radical decision as a call to action — specifically, to pass a bill they can put on the table now and campaign on in 2020.

That’s smart politics. There’s a substantive reason to act as well. Unfortunately, ACA enrollment has peaked, leaving 28 million Americans uninsured, and marketplace enrollment in private plans now falling. Premiums are too high and consumer choice too limited in many parts of the country.

It is time to put a real fix on the table, recognizing that this probably cannot become law until Democrats regain control of the Senate and White House. Simply proposing Medicare-for-all may galvanize the Democratic base, but it might not even pass the House and could well cost Democrats dearly in the 2020 election. But Medicare is popular, and the ACA can be improved by borrowing from it.

First, let’s be clear about objectives: The ACA needs to cover more people and bring down premiums. Both goals require addressing the root cause of runaway health care spending: prices.

The United States spends twice the average per person of our peer countries, not because we use more medical services, but because of higher prices for the medical services we do use. In fact, we see the doctor far less often, use half the hospital days, and swallow roughly the same number of pills as Europeans and Canadians. We pay on average twice what other advanced economies do for each visit, day, operation, scan, or pill.

Medicare-for-all would change that, but it is still a bridge too far for many voters, even moderate Democrats. Having come so close with the ACA — 91 percent of Americans are covered — a wholesale switch would be very disruptive. Rather, a reinvigorated ACA should build on tested elements of existing federal programs, just as the ACA built on tested elements of Massachusetts’ reform, to achieve the twin goals of coverage and cost.

To start with here are three relatively simple fixes that would materially improve the ACA, building on some of the best policies in other programs:

First, concede the individual mandate. Get rid of this unpopular “stick” and increase the ACA’s carrots. For 12 years now, Massachusetts has offered higher subsidies than the ACA’s national schedule of tax credits. As a result, nearly everyone (97 percent) in the Commonwealth is covered. So let’s replace the mandate with more generous premium subsidies under the ACA and, if some sort of stick is still required, then the ACA should allow insurers to surcharge premiums for those who wait until they get sick to buy coverage, just as Medicare drug plans do now.

Second, to ensure competition and choice in marketplaces across the country, bring back the “public option” that was originally considered for the ACA. This doesn’t have to be government-run insurance; rather, we could deploy private Medicare Advantage plans on the ACA marketplace. These private plans now enroll half of all newly eligible Medicare beneficiaries. They combine competition and relatively low (Medicare) pricing levels for hospitals, doctors, and other care providers. (Remember, it’s high pricing that accounts for our high total medical spending.) So let’s have these same Medicare replacement plans compete for younger individuals in the ACA marketplace.

Third, let the government negotiate drug prices, as the Veterans Affairs department and so many of our peer countries do, both for Medicare and private Medicare replacement plans. The VA pays far less than commercial insurers for the same drugs. Let’s share those savings with current Medicare enrollees and the individuals who chose Medicare replacement plans in the ACA marketplace.

These are three easy-to-understand, workable fixes for the ACA. Are they controversial? Of course. Lowering the costs of coverage means taking money away from powerful interests, including people who save lives for a living. We revere them — when we’re not cursing them for overcharging.

But America now faces the choice of making coverage affordable or halting recent coverage gains — likely to slide backward in the next recession. Or we can build on the ACA, using some proven health policies from the federal tool chest.

No one is saying the Affordable Care Act is perfect. As the introduction to this post stated, even former President Barack Obama admitted Obamacare has its shortcomings. So why have efforts to repeal, replace or repair it failed in such spectacular fashion?

Part of the problem is that healthcare is hard. (Who knew?) It’s a big, expensive, complex and highly regulated industry that accounts for one-sixth of the nation’s economy and, quite literally, involves matters of life and death.

As the summer winds down and Congress prepares to get back to business, we hope that healthcare reform doesn’t fall off the agenda. President Donald Trump vacillates between demanding that Congress take immediate action—suggesting he’ll sign just about anything that crosses his desk—and threatening to let the ACA fail.

Neither tactic is viable.

In this special report, FierceHealthcare’s editors—experts on the business of healthcare who cover hospitals, health systems, physician practices, insurance companies, health information technology, and healthcare finance every day—outline some of the ideas, programs and reforms that hold the most potential to heal the nation’s healthcare system.

It starts with politics, as in knock off the bipartisan bickering and gets to work. Hold hearings and get input from the people who are the heart of healthcare, from doctors and nurses to health insurance executives to patients and their advocates.

And while the nature of compromise is that no one will be totally happy with the outcome, buy-in is more likely when there’s real dialogue, transparency, and honesty.

That dialogue can start with the ideas presented in this report, which explains how the U.S. can:

  • Work to find common ground and easy wins … and cool off the political rhetoric.
  • Stabilize the individual insurance marketplace while lowering premiums and staving off the “death spiral.”
  • Fix healthcare regulations so they free, rather than strangle, those who are trying to make the system better.
  • Continue to build reimbursement models that encourage providers to improve quality and lower costs.
  • Harness the power of technology and innovation to cut costs and improve access to care.
  • Reform how—and control how much—the country pays for healthcare, including tests, procedures, and prescriptions.
  • Ask industry stakeholders for the input—especially the clinicians who are the heart of the healthcare system.
  • Let states lead the way with Medicaid innovation and other reforms.

The most important thing to fix the ACA is to find a bipartisan solution

         The Affordable Care Act has problems, but the right and the left must work together to find a solution. Over the next few weeks, I am going to expand on the 8 suggestions for improving the Affordable Care Act. But it has to come from both parties and not be a battle to get reelected or to shame former President Obama or to shame and embarrass president Trump and the Republicans.

Gienna Shaw noted in August of 2017 that in the 7 years after it was passed in October 2009, the House of Representatives voted more than 50 times to repeal or amend the Affordable Care Act. As the count climbed toward 40, the editors at FierceHealthcare began to debate whether we should continue to write about each and every House effort, knowing that no bill would ever pass the Senate, let alone get by then-President Barack Obama’s veto pen.

This year, the GOP—with majorities in the House and the Senate and a Republican in the White House—came closer to repeal (or at least “skinny repeal”) than ever before. But they still haven’t managed to repeal or replace the healthcare reform law, which has been steadily growing in popularity among voters.

Over the years, the debate shifted focus from intrusive big-government boondoggle to the right to affordable and equitable healthcare. Yet many lawmakers are reluctant to recognize that and change gears.

But here’s the thing: The Affordable Care Act really does need to be fixed. Premiums for individual insurance plans really are skyrocketing. The United States really does spend more on health care than other wealthy nations, yet ranks dead last on equity, access, efficiency, care delivery, and healthcare costs.

The only way to reverse those trends and fix the Affordable Care Act is for Republicans and Democrats to come together and find a bipartisan solution.

Even Obama has said the healthcare reform law needs a bipartisan fix, although, at the time, Republicans panned that overture. Perhaps that attitude is changing in the wake of more failed efforts to repeal the ACA and the emergence of a group of Democratic and Republican lawmakers who’ve dubbed themselves the Problem Solvers Caucus.

Co-chaired by Rep. Tom Reed, R-N.Y., and Rep. Josh Gottheimer, D-N.J., they’ve already come up with a set of recommendations that draws on ideas from both sides of the aisle. “The last great hope for this country is that Republicans and Democrats prove they can work together,” Reed said recently.

It’s a good start, but fixing healthcare will require a dedicated, sustained effort, and that starts with two immediate steps:

Tone down the rhetoric

The right uses “Obamacare” as a pejorative, and “Trumpcare” is a dig when it comes from the left. President Donald Trump is fond of calling Democrats obstructionists and has said they have “no good ideas.”

And although it’s difficult to participate in the debate when you’re largely barred from deliberations, Democrats could stand to be more open about the ACA’s problems and must be very clear about what policies and solutions they’re willing to back, taking steps beyond their opposition to full-on repeal.

And let’s not forget that both sides have suffered their share of marketing missteps. (Think Obama saying, “If you like your doctor, you can keep your doctor,” and Senate Majority Leader Mitch McConnell describing one version of his own party’s repeal efforts as a “pig in a poke.”)

Hold hearings

It’s astounding that this even has to be said, but rather than crafting legislation behind closed doors and asking members to vote for it even if they do not want it to ever become law, it’s time to let the sunshine in.

Sen. Lamar Alexander, a Republican from Tennessee, has promised that the Senate Health Committee will hold bipartisan hearings on how to repair the individual insurance market, but talks need to go much further than that. And testimony should come from health insurance industry leaders and providers, including the nurses, doctors and other clinicians who are at the heart of the healthcare system. Listen to health information technology innovators, from the big-name companies to the scrappy startups that are trying to improve care quality and lower costs, and don’t forget to include employers.

And take a best-practice lesson from those in the healthcare industry: Focus your discussions around caring for patients, always.

Many organizations have a patient advisory board or put patients on their boards of trustees. Some payers and providers even have rules that every meeting must include at least one patient. Patients and their advocates need a seat at the table in Washington, too.

Consider tax, regulatory relief

Some lawmakers want to raise the employer mandate threshold so that businesses with fewer than 500 employees don’t have to provide coverage to their employees.

Starting with the first suggestion Leslie Small suggested that if lawmakers want to tweak the Affordable Care Act without kicking up too much controversy, they could consider targeting some of the law’s wonkier provisions.

There’s common ground to be found in several of the law’s taxes, which are unpopular with the healthcare industry and politicians. There are plenty of provisions that are easy to hate.

One low-hanging fruit: the medical device tax, which is largely reviled by device manufacturers and was set to be done away with in several iterations of Republicans’ Affordable Care Act repeal bills.

Insurance companies would be happy if lawmakers did away with the health insurance tax, which they say contributes to higher premiums. Even some conservative groups have recently begun to call for a repeal of this tax.

Employer groups, meanwhile, have called for a full repeal of the so-called Cadillac tax on high-cost health plans. That tax is so unpopular that it’s never actually been implemented: It was delayed for 2 years as part of a 2016 spending bill that also delayed the health insurance tax and the medical device tax for a year.

Speaking of employer-sponsored coverage, some business groups would likely approve of an idea floated by the self-dubbed Problem Solvers Caucus composed of GOP and Democratic lawmakers.

The caucus wants to change the employer mandate so that only those with 500 employees or more—rather than 50 or more—are required to provide coverage to their employees. Proponents argue that would stimulate the economy: Small businesses accounted for 64% of the net new jobs created between 1993 and 2011, according to the U.S. Census Bureau.

“The current employer mandate places a regulatory burden on smaller employers and acts as a disincentive for many small businesses to grow past 50 employees,” the caucus said in an announcement.

Ramp up technology, innovation, and data

Healthcare reforms aren’t likely to succeed without accounting for health IT innovations like telemedicine and data analytics.

Evam Sweeney continued the discussion in that there’s no question the Affordable Care Act is in need of some legislative fixes, but underneath those policy bandages, technology is already transforming the way the industry treats patients and pays for care.

That undercurrent of innovation could use some nurturing as well, particularly as payers and providers look for ways to provide more efficient, value-based care.

The rise of telehealth is a perfect example. This year alone, lawmakers have submitted half a dozen bills to expand or reform telehealth payment in some way. Medicare and Medicaid coverage for telehealth services is still sorely lacking, and the nation’s top insurance companies have been pleading with the feds to remove the barriers to telehealth reimbursement.

States have made some progress when it comes to paying for telehealth and enacting parity laws, but those laws aren’t keeping pace with the relentless advancements of virtual care.

That’s not stopping providers from investing in telehealth technology, and most healthcare executives will admit that even though reimbursement is a struggle, the thought of being left behind is even more unsettling.

Admittedly, the CBO scores for telehealth bills are messy, but there’s little doubt that virtual care brings a slew of benefits by keeping patients at home and opening up access in rural parts of the country, where patients would otherwise spend hours traveling to the nearest medical center or forgo care altogether. Expanding payment models—a notably bipartisan issue—will provide support to local initiatives that are already well underway.

At the same time, data have become tools that both payers and providers can’t live without. The problem: Most healthcare data are still unusable.

Quantity is not an issue—there’s a seemingly endless stream of healthcare data, and more on the way as patient-generated data gain a bigger foothold. The problems boil down to quality and usability.

Solving these two issues will be critical as the industry turns to data analytics to improve care, reduce costs and validate new payment models. Although there have been pockets of success thanks to burgeoning data-sharing partnerships between payers and providers, medical data are still difficult to untangle, and cleaning patient data is still incredibly burdensome.

Obtaining clean, usable data will serve as the backbone to deploying predictive analytics and machine learning that can predict illnesses, reduce unnecessary hospital visits, support population health initiatives, streamline care and reveal the best treatment options for patients with chronic illnesses.

Better data-sharing arrangements between payers, providers, researchers, government agencies and patients will speed the discovery of cutting-edge treatment options and advance precision medicine. But all of those efforts will be slow to mature without concerted (and coordinated) efforts to standardize data collection and dissemination across multiple platforms.

Ask the doctors

How would doctors fix the Affordable Care Act? It’s time to ask them. Joanne Finnegan asked the question How would doctors fix the ACA? The politicians in Washington have struggled and failed to come to an agreement about how to fix the Affordable Care Act. Now it’s time to call the doctor. Why? Because you can’t fix the healthcare system without involving the physicians, nurses and others who are at its very heart.

“Would you want to fly in a plane with no input from a pilot?” Matthew Moeller, M.D., a gastroenterologist, asked in a post on the popular doctor’s blog KevinMD. “Or design a curriculum without a teacher’s input?”

Throughout the fight over the ACA, physicians—or at least the medical organizations that represent more than half a million frontline doctors—have stood in opposition to plans that would result in patients losing healthcare coverage.

Doctors want a healthcare system that supports the physician-patient relationship that drew most of them to medicine in the first place.

While they are strong advocates for their patients, doctors can still make a difference in controlling costs. If you want to change the “more is more” culture in medicine, doctors can help.

Physicians are the ones who order tests, write prescriptions, hand out referrals and perform complex treatments. They can adjust their clinical practices to accommodate cost considerations without shortchanging patient care.

Does a patient with high blood pressure really need to come to the doctor’s office every 3 months? Wouldn’t it make economic sense to teach a capable patient how to check his or her own blood pressure at home and fax or email results into the office?

In fact, some of the most revolutionary healthcare reform ideas center on doctors. For example, Jody Tallal, a personal finance manager, says the country could ensure healthcare for low-income Americans by offering tax credits to doctors. Instead of reimbursing doctors through Medicare and Medicaid, the country could provide a dollar-for-dollar income tax credit to doctors who provide care for the poor.

Many doctors like the idea of a single-payer system, even if it’s a pipe dream for now.

Fred N. Pelzman, M.D., of Weill Cornell Internal Medicine Associates in New York City, for instance, says it’s time the country moves toward providing Medicare for everyone in order to provide a baseline level of care, which could be supplemented by private insurance for those who want and can afford it.

“This country needs a safety net that is a little less exclusive,” he says. “You should be able to get the care you need and if you want to see the world’s greatest heart surgeon, you figure that out.”

Doctors are already central to one reform movement: the change away from fee-for-service medicine to value-based payment. They’re in the first year of a new Medicare payment system established under the Medicare Access and CHIP Reauthorization Act of 2015, which will determine how clinicians get reimbursed under the Medicare program.

But the regulatory and administrative burdens continue to increase. For many doctors, the start of any healthcare reform needs to ensure there is less regulation, with its demoralizing administrative requirements dictating how they provide care, drowning them in paperwork and leaving them struggling with poorly designed electronic health record systems.

Doctors have long complained that all of it takes them away from providing care for their patients. The goal of any healthcare reform legislation should be to ensure that the patient-provider relationship remains sacrosanct.

Next week I will continue the discussion on fixing the ACA/ Obamacare!

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