Physicians have long advocated health insurance coverage for all Americans, but with the Affordable Care Act (ACA) under the microscope and fierce division about whether or how to replace it, the lens of the future has become cloudy. At its National Advocacy Conference in Washington, D.C., the AMA engaged with three people deeply knowledgeable about health care policy in a panel discussion on what could be ahead and how medicine will address the needs of patients in an uncertain future.

Richard A. Deem the AMA's senior vice president of advocacy, first engaged James C. Capretta, resident fellow and Milton Friedman Chair of the American Enterprise Institute, on how a new plan may look if certain ACA revenue sources are repealed.

Deem: If the reconciliation bill repeals the ACA revenue streams, such as the “Cadillac tax,” the employer tax and the medical device tax, will there be sufficient resources to avoid a regression in the number of Americans with health insurance and fund the replacement?

Capretta: [Will] you have enough to make up for that huge reduction on the pay-for side? Probably not. So there’s going to be a collision there. They’re determined … to really get rid of those taxes. That’s another collision, one of many that are still awaiting analysis.

Deem: Many patients do not have the savings to cover a [high] deductible or other out-of-pocket costs, or have the salary to contribute to a health savings account. How is that going to work in terms of affordable coverage for everyone? Are there going to be, from what you’ve seen so far, the supports for people to truly access and purchase real coverage?

Capretta: Two things I’d say about this. One is related to the Medicaid equation. At the end of the day, the idea [is] that they are going to have a significant rollback of populations currently on the Medicaid program. The politics would be very difficult for that and I think they’re going to have to think of some kind of combination between the expansion and non-expansion states. There is an equilibrium that’s probably somewhere in between … but that would mean that a lot more people will still be on the Medicaid program.

With respect to the tax credits, I agree that the simple age adjustment on it is going to be about 125 percent bottom line [to] 250 [percent], with a lot less resources than they get with the ACA tax credit. That’s going to be a problem. I think that they’re going to have to give a little bit on that as well, because they want to make sure that they can show the public they’re still going to have very affordable—or some kind of access to an affordable plan.

Insurers are paying close attention to how reform efforts are shaking out to inform how they will react if or when a plan is presented. Deem investigated the insurer perspective with Matt Eyles, executive vice president of policy and regulatory affairs at America’s Health Insurance Plans.

Deem: What are the two or three things that the insurance industry needs to have happen in the next few months to stabilize the individual market?

Eyles: The first one is regulatory certainty. There’s a proposed rule that the administration issued very quickly, by most standards, and trying to get that finalized so that people understand what the rules of the road are around things like special enrollment periods.

We recognize that there are legitimate reasons for special enrollment periods. We would just like to see them more aligned to what you see, for example, in typical employer coverage. That is, if you make an election during your employer’s open enrollment period in the fall, [then] you decide, “You know what? I don’t want coverage,” then you can’t all of a sudden, in the middle of the year, revisit that decision. So some more certainty around that I think would be important.

Certainty around what’s going to happen with attachments—when subsidies and premiums are being turned in. I don’t think we’re going to get that answer in time.

And then, finally, I’ll call it additional stabilization funding. For example, the risk mitigation funding that was in place in the first couple of years of the program.

This is not the first time health-system reform has been attempted. It is a long-term, continuing process. Deem spoke with Charles N. Kahn III, president and CEO of the Federation of American Hospitals, about past efforts and reducing the regulatory burden.

Deem: What are the lessons we’ve learned from the past exercises that should be carried forward, and what are some of the things that may have been successful?

Kahn: Let me just approach one aspect of it, which is the political aspect. It seems to me that there’s a conversation going on … between very few people. You’ve got a cadre in the House, a cadre in the Senate. You have the insurers because of necessity. Not because they necessarily want to be [involved], but because they have to be because of the stresses on the market.

What’s curious to me is there really isn’t a conversation with all the other stakeholders in the health care system. Maybe I’m missing something, but I don’t see a big conversation.

What happened in ... ’93–’94, you could make an argument that by the end of that ClintonCare process, not all, but almost all, of the major players had big issues with the policy proposals or just outright opposed it by the end.

Back in 2009 and 2010, they obviously had a different situation, but their priority was to bring everybody into the house they could from the stakeholder community and that was what the White House did.

What I see here is something that’s troubling because I think they, unlike ’93–’94, will be able to legislate if they choose to—they’ve got to work out their right and left problems. But to me they’re not that interested in how the outside world views this other than the governors and the insurers… And I think this is a mistake and it will come back and haunt them.

Because at the end of the day, whether it’s the consumers or those in this room (physicians) in the hospitals that have to deliver the care, everybody should be part of this dialogue and that may send it in some direction that some of these guys don’t want it to go … but I think they’re going to avoid it.

Deem: There’s a big opportunity here for the entire sector to relook at some regulatory burdens. Some things that are in the way across the system don’t necessarily contribute to better health care. What are some of the opportunities that you see in terms of regulatory changes for health care delivery that could make a difference?

Kahn: All the urgings of HITECH [Health Information Technology for Economic and Clinical Health Act] and the implementation of value-based purchasing in all of its various forms, whether it’s reforms that are in place now or in MACRA, which is in the process of being implemented, on the IT side; in all those areas we do need a reevaluation. We do need to get back to first principles—what are we trying to accomplish? I think probably less is better.

There’s no argument anymore that it is better for patients to have an electronic medical record and that they’re interoperable. All that being said, the complexity that’s been put on top of it is actually not that good for patients. It clearly makes the workflow of providing and delivering care more complicated.

I’m not sure we’re achieving those things we can achieve. I think there needs to be a reevaluation of that as we go into the implementation of all the aspects of value-based purchasing and—at the end of the day, with all the best of intentions—I think the previous ... administration was heading us in a direction where all of these things were just going to be more compliance, and not helping the patient and facilitating better care and advancing what hospitals and clinicians can do.

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