Back in March, I made some observations about the AHCA, the bill to “repeal and replace” the Affordable Care Act that was ultimately passed by the House of Representatives and both hailed and disparaged by the President. Some of the naked political calculus that facilitated the passage of such a truly despicable bit of legislation was the belief that the Senate would somehow rescue the Republican Party from itself and restore something “beautiful.” Well, it is now pretty clear that the Senate bill – cynically dubbed the “Better Care Reconciliation Act of 2017” – is no better than what the House threw over the fence.
The bill retains essential “features” of the House version: less funding for Medicaid, fewer constraints on bad behavior of insurers, leaner subsidies for the uninsured to buy insurance, and repeal of the mandate to buy insurance for those with neither employer provided insurance or eligibility for Medicaid or Medicare.
I think Paul Krugman explained pretty well why the current plans to dismantle parts of the ACA don’t work. The ACA is based on a few interdependent ideas:
- For insurance to be useful, it has to have certain features, like broad benefits and inclusion of people with pre-existing conditions
- To avoid the insurance “death spiral,” everybody has to be in the risk pool. Otherwise, only sick people would buy insurance, thereby pushing up the price and making those who are relatively healthier drop coverage, driving up the price further and driving more healthy people away, worsening the problem
- To facilitate getting everyone in the risk pool, subsidies are provided to those who can’t afford the premium
Remove any one of these and the system collapses. We are likely to end up with fewer people insured and worse coverage for those who buy insurance. As is true of the House bill, the Senate bill does nothing to address the real challenges facing our healthcare system today – access, quality, and affordability. As the President might say: “sad.”
What do you think?
While Washington now seems consumed with the mess swirling around the White House that was triggered by the abrupt firing of the FBI director, I want to get back to the mess swirling around the latest effort to “repeal and replace” the Affordable Care Act.
Although the President stated that “nobody knew that health care could be so complicated,” his apparent surprise is surely based on his own profound, willful ignorance. Anyone who has paid even the most cursory attention to American health care delivery and financing knows that our “system” is uniquely complicated (actually, it is complex). The complexity has been driven by many forces including, among others, the historical accident of employer-based health insurance, a mythic belief in “the market” to improve everything it touches, a corresponding skepticism that government can do anything effectively, and a lack of national consensus about what we, as citizens, owe each other to “promote the general welfare.”
The net result has been well documented. Health care in America is characterized by huge disparities in access to care, major failures of quality and safety, and unsustainable costs. It is, of course, also characterized by amazing life-saving and life-sustaining technology and millions of dedicated, compassionate people who struggle daily to overcome the dysfunction to deliver great care. So how to fix the bad without destroying the good?
Continue reading Back to Health Care
Everybody knows the old saw about how the legislative process resembles a sausage factory: even if you like the product, it may turn your stomach to see how it is made. I have been thinking about that metaphor a lot lately as I have watched the Republican caucus in the US House of Representatives slap together their plan to “repeal and replace Obamacare.”
As the House lurches toward a critical vote today, I offer a few personal observations:
- The Republicans have long complained bitterly about how the Democrats “rammed through” the ACA in 2009. This, despite the fact that there were months of negotiations and the bill incorporated many previously mainstream Republican principles (including the individual mandate, which now seems anathema), and the Republicans deliberately walked away as part of their obstructionist strategy to deny President Obama a legislative victory of any sort. It is therefore particularly disturbing to see them scramble to bring this dog of a bill to a vote on some arbitrary self-imposed deadline. What is the rush?
- Speaking of a dog of a bill (with apologies to dogs everywhere), the only “principle” or “goal” that it advances is checking a box that says “repeal Obamacare.” The challenges facing our health care system are pretty easy to categorize. We need to assure access to care, we need to improve care, and we need to control costs. This bill does none of those things and stands to reverse the progress made by the ACA in providing coverage for millions of Americans.
- Don’t be fooled by claims of “lower costs.” The only thing this bill would lower is coverage, mostly by throwing millions off of Medicaid, and by stripping covered services from ACA plans. Any accrued “savings” are achieved by just providing less care for those who are in need.
- The targeting of Planned Parenthood and of reproductive health services, in general, is a shameful demonstration of the deep hypocrisy in the Republican party that has stood for individual choice and limited government (well, at least back when the party stood for anything at all) until it comes to dictating women’s health choices.
- The proposal is demonstrably, clearly, unambiguously and completely at odds with the President’s stated goal of “repealing Obamacare and replacing it with something beautiful” that “covers everybody.”
- Mostly, I am saddened by this rush to do harm, driven by political expediency, facilitated by ignorance, and leavened by a callous disregard for the health and wellbeing of our fellow citizens
What do you think?
We held a retreat last week for the Board of Governors of Northwell Health Physician Partners. Because we have matured as an organization, the agenda was different from recent years. Instead of asking “big questions” about what the group is and should be, we focused on providing information to the Board, and on addressing ways in which we could reduce physician burnout.
Given the imminent inauguration of the new president, and his party’s pledge to repeal the Affordable Care Act, one of the informational sessions was devoted to how the changeover in Washington may affect health care policy. We heard from Northwell Health’s head of government affairs, and from a former senate staffer who now works for a firm that provides our organization with insight into what is going on inside the beltway.
The speakers were knowledgeable and engaging, and I am confident that their description of the incoming administration and of the plans being laid by the new congress was accurate and insightful. It is no criticism of them to also say that I found their description appalling, frightening, and depressing.
Here are a few “highlights”:
Continue reading Repeal and… Then What?
I was driving to work the other day, and there was a story on the radio about the Congressional reaction to the latest recommendations for breast cancer screening from the United States Preventive Services Task Force (USPSTF).
Here’s the background. USPSTF published recommendations in late 2009 for the use of screening mammography in different age groups. For women between 40 and 50 years old, the panel concluded “that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older.” In other words, they did not recommend biennial mammograms – which they did for women between 50 and 74 years old – for the younger cohort. That led to a firestorm of criticism that younger women would be “denied” mammography, and Congress wrote into the Affordable Care Act that “exchange” (Obamacare) insurance plans cover regular mammography for women over 40.
Fast forward to now.
Continue reading Congress and Dr. Bayes
When the Affordable Care Act (ACA) was passed in 2010, the most contentious provisions – which are still the subject of challenges in federal courts – were the establishment of state-wide insurance exchanges, the “individual mandate” that compels eligible citizens to buy insurance, and the expansion of state Medicaid programs. Less well appreciated, but arguably more important, were a wide range of reforms to the Medicare program. Summarized here, they touch on almost all aspects of the program, but I want to concentrate on just one.
The law directed CMS to move Medicare from a strictly fee-for-service (FFS) payment model (“paying for volume”) to one in which the quality of care was factored into the payment received by hospitals and physicians (“paying for value”). As I have written previously I believe this is the right move. There are just too many challenges to improving care and lowering costs that derive from “straight” FFS that is disconnected from any assessment of quality. And while you may not have known that they grew out of the ACA, the payment reforms themselves have gotten a lot of attention. Penalties for readmissions, requirements for physician quality reporting, pilot programs for bundled payments and accountable care organizations are just of few of the Medicare reforms. Even though they currently influence a small percentage of overall Medicare spending, these changes may already be having a big impact on how care is delivered.
Continue reading Not Your Father’s Medicare
About a year ago, I shared details of my own out of pocket medical expenses and concluded that we have to have to be more transparent with our patients (and potential patients) about the costs they will face for our services. The urgency of price transparency as a business imperative and a professional responsibility has only increased since then.
Consider that we are now a year in to the implementation of the Affordable Care Act. Everything that I have read suggests that consumers were intensely price sensitive when it came to choosing which plans they elected. Well, duh! The benefits are defined by “metal” levels (e.g., Bronze, Silver, etc.), and there is almost no way for people to compare the quality of competing narrow networks or individual providers, so price differences drove decision-making. Likewise, the healthy people who bought insurance because they were compelled to by the individual mandate generally chose high deductible plans to minimize their monthly payments. This, in turn, makes them much more price sensitive at the point of care. That means that patients may resist recommended treatment. It also means that physician offices will face more challenges in collecting fees from patients who have not yet met their deductible for the year. At the very least, patients will be more interested in learning what costs they will be exposed to.
Continue reading Price Transparency
There were 2 articles in the New England Journal of Medicine this past week that caught my eye. Although they appear to address very different subjects, I believe they have an important connection. Continue reading Health Care Costs
There has been a lot of understandable outrage over the troubles plaguing Healthcare.gov, the federal website for purchasing individual or family health insurance under the Affordable Care Act (aka Obamacare). Opponents of the law (Republicans), recovering from their self-inflicted wounds over the government shutdown, see this as evidence of the fundamental unworkability of the law, and of the folly of a “government solution” to a complex problem. Supporters of the law (Democrats) are terrified that the difficulty in buying insurance will dissuade the so-called “young invincibles” (healthy young people who have limited needs for health care services) from buying coverage. Continue reading Functioning Health Exchanges
The irony continues. The federal government is “shut down” but health insurance exchanges at the center of the law that provoked Republicans to hold the country hostage have been up and running, and attracting a lot of interest. Although there have been some well-publicized (and expected) technical glitches, millions of people have visited State and Federal websites to learn more about their options for purchasing health insurance.
At the same time, the New York Times reported this week that millions of other citizens, who have incomes too low to qualify for subsidized private insurance on the exchanges, will continue to be uninsured. Remember that the Affordable Care Act was designed to expand health insurance coverage in two ways: for those with the lowest incomes, states were offered new funds from the federal government to expand Medicaid, which would have covered nearly all of the new expense at the outset, and about 90% thereafter. For those with higher incomes, the exchanges were created to provide new access to private insurance and subsidies based on income. Continue reading Week Two