Apr 05, 2017

Physician Viewpoint: Obamacare, Trumpcare…Changes Needed

The first-time failure to garner enough congressional support to erase and replace the Affordable Care Act (ACA), known also as Obamacare, leads to the next, logical question: where do we go from here?

Don’t think President Donald Trump, the House and the Senate will drop the issue entirely. As he told us in the months leading into last year’s election, the President quickly wants to erase and replace the ACA. As they demonstrated for years since its enactment, GOP leaders now controlling Congress remain eager to do the same.

But for now, good guidance comes from Green Bay. To quote Aaron Rodgers, Packers’ quarterback and an expert in his own field, as his football team looked last fall to recover from a series of lost games to make the NFL playoffs: “Relax.”

Separate rhetoric from reality. Keep in mind that change is very likely – and important changes are much needed. Also, some changes will be difficult to handle, but not impossible.

Health care providers know the ACA has tremendous shortcomings, especially evidenced by people having fewer (sometimes no) coverage options after major insurers drop out of state and regional markets that prove to be money-losers (Texas being one of them). Too often, patients must change health plans, only to find their current doctors don’t take the new insurance. This forces providers to expend resources to help patients find plans they accept or find a new doctor that takes the new insurance. This process also means patients have to reestablish their medical history with a new doctor, and start from the ground up again in developing a trusting patient-doctor relationship.

It’s increasingly apparent that Republicans and Democrats agree there’s fundamental value in health care plans being widely available and generally affordable. While they will quarrel along the way, I think they now will take some time to unwind, analyze and logically reconfigure this huge national initiative as it now stands.

Changes to the ACA are inevitable. Repealing it is not. It will take some time for the U.S. House to untangle itself from the repeal/replace effort in March. And with just 52 seats in the Senate, Republicans are eight votes shy of the 60 required to completely say goodbye to the ACA.

However, aspects will be repealed as part of the federal budget reconciliation process, which only requires a congressional majority to approve any change. So, the 52 Republicans, if unified, can act on their own. They need just 51 votes (or 50 and Vice President Mike Pence’s tie-breaking vote). (Looking to get into the weeds of budget reconciliation? Read this piece: Budget Reconciliation Explained Through Chutes And Ladders.)

What parts will be repealed? Gone will likely be mandated penalties on employers who don’t provide coverage to workers and people who declined to purchase individual policies.

Gone too, I expect, are ACA taxes; federal subsidies for policies purchased on Healthcare.gov by those with low incomes; and federal funds to expand Medicaid at the state level. How this pencils out financially for the feds will be interesting to see, but all these steps could lead to fewer patients possessing health insurance and being financially able to fully pay their bills.

What will remain? Both sides — Democrats and Republicans — are in agreement that coverage should be offered until age 26 and that no one should be denied for pre-existing conditions.

We will also see longstanding “pay for procedure” processes wane and “pay for performance” grow – if not in popularity, then by necessity. It must, with the increasing and unsupportable financial burdens health care places on patients and public entities.

For example, bundled payment models for many Medicare cardiac and orthopedic patients in 98 U.S. metro areas, already in place, will proceed as scheduled on July 1, the U.S. Department of Health and Human Services announced in February. It won’t be subject to any of the President’s early executive orders.

ACA-prescribed Medicare delivery system reforms, such as the Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs), haven’t been targeted yet in Washington. Same with the Medicare Access and CHIP Authorization Act (MACRA), passed with bipartisan support by Congress in 2015 separate from the ACA.

I hope both sides reconsider and perhaps expand the original Medicare Advantage model of capping patients’ costs by letting doctors and nurses better navigate their care – and, in the process, cut costs in providing care. Something like this is imperative because, if providers can’t cut costs, they can’t make enough money to keep their doors open. Our patients – and our society – would suffer.

Medicare Advantage has faced significant political and budget pressure, and benchmark cuts under the ACA probably will remain in place. However, I’m hopeful the Trump administration and Congress are open to the solid arguments for saving and enlarging this initiative.

There is room for compromise (and common sense). For example, three specific delivery system improvements are “win-wins.” They can contain insurance costs while enhancing patient care. In addition to value-based payment approaches, we need coordinated use of health information technology and improved quality measurement.

These three delivery system improvements are linked in many ways. Combined, they move our country from fragmentation to integration, from volume- to value-based payments and from paper records and isolated computer records to interoperable, comprehensive online databases.

At the end of the day, I trust it’s going to work out and, I hope, turn out to be more orderly. We’re really talking about evolutionary change in health care delivery. Some changes may not prove effective, but corrections can be made afterward.

All this can and probably will create some new angst for medical care providers, as well as patients. However, I’m confident we can adapt, as we have proven we can over past decades that saw monumental changes in and around medicine.

Jay Zdunek, DO, MBA, is the Senior Medical Director and a Family Medicine physician at Austin Regional Clinic located in Central Texas.

Tags: Jay Zdunek, DO, Leadership Blog