Election 2016: What Now for Healthcare?

This week has been one heck of a roller coaster ride for the healthcare industry.
Administrators and providers who spent the last six years preparing for a future based on the Affordable Care Act (ACA) are justifiably antsy. Will all their hard work and spending be for naught? Or will the new administration find a way to improve access and quality?
It will probably be a few months — years even — before we know the answers. But while regulations may change, experts seem optimistic that The Triple Aim of quality, population health, and consumer experience will not.
In today's post, we'll look at what advocates, professors, payers, lawyers, and Vituity providers have to say about your most pressing questions.

How likely is a day-one repeal of the Affordable Care Act?

  • Our sources say: Very unlikely.
President-Elect Trump has made his plans for "Obamacare" clear. From his campaign website:
Obamacare is certain to collapse of its own weight, the damage done by the Democrats and President Obama, and abetted by the Supreme Court, will be difficult to repair unless the next President and a Republican Congress lead the effort to bring much-needed free market reforms to the healthcare industry.
But none of these positive reforms can be accomplished without Obamacare repeal. On day one of the Trump Administration, we will ask Congress to immediately deliver a full repeal of Obamacare.
The president-elect has since clarified that he's in favor of retaining some Obamacare provisions (e.g., guaranteed issue, allowing adult children to remain on family plans until age 26). But even if seeking a less-than-complete repeal, Trump may learn that he who campaigns in poetry must govern in prose.
On the practical side of things, the Democrats have enough Senate seats to block a complete repeal and replacement. Then there's the fact that over the past six years, the ACA has taken root in many areas.
In his excellent post for Health Affairs Blog, health law prof, IOM member, and consumer advocate Timothy Jost, JD, points out that the ACA isn't just about insurance. It affects every corner of our healthcare system. A day-one repeal would bring key programs like Medicare screeching to a halt, which certainly isn't something either side wants to see happen.

The ACA is inextricably interwoven into our health care system and is not going away immediately. — Timothy Jost, JD

A day-one repeal raises another question: if you're going to take coverage away from 22 million people, what do you replace it with? At the very least, it would take a few years to obtain the needed commentary to enact replacement regulations.

That [repeal without replacement] is a nightmare scenario. — John McDonough, DrPH, MPA, Professor, Harvard School of Public Health

Such a reduction in coverage would also be unprecedented in our history.

I don’t think there has been a reversal of any public benefit that would be as large as this. The only other significant reversal by Congress of a major health-care policy — the expansion of Medicare to include catastrophic coverage — took place in 1989 before the benefit took effect. — Larry Levitt, Senior Vice President, Kaiser Family Foundation

And, it's probably safe to say, politically unpopular.

One should never underestimate an extraordinary backlash that occurs when people have something that they really value and it is taken away. — Ron Pollack, Executive Director, Families USA  

Whatever their feelings about the ACA, it's doubtful that Republican lawmakers want to strand millions of constituents without coverage.

I don't think Republicans want to come in and pull out the rug from a lot of people. This was a populist movement. — J. Mario Molina, MD, CEO, Molina Healthcare 

So at this point, a complete day-one repeal looks unlikely. But that doesn't mean the new administration is powerless. It simply brings us to a new question …

Could Congress defund the ACA rather than repealing it?

  • Our sources say: Yes, but it's complicated.
Congress successfully used the budget reconciliation process — which requires just 50 Senate votes — to defund key provisions of the ACA in 2015, including tax credits and individual and employer mandates. President Obama vetoed that bill. But if the feat could be repeated, President-Elect Trump would presumably be receptive.
However, this could set up an interesting Catch-22. The reconciliation process can't touch non-budget regulations, such as prohibitions against pre-existing condition exclusions and basing premiums on health history. And Present-Elect Trump has also expressed support for retaining these.
Such regulations are expensive. From the payer's point of view, they only work if there are young, healthy people in the coverage pool to offset the risk. Hence the ACA mandate that everyone have insurance, whether they believe they need it or not.
So if Congress repeals the mandate with guaranteed coverage in place, what could happen?

If you take one of those away, this doesn't work. If you want to get rid of the mandate, you have to go back to underwriting. — Craig Garthwaite, MPP, PhD, Kellogg School of Management, Northwestern University  

And if insurance companies can't keep afloat, we're all in trouble.

The continued imposition of these requirements without the financing provided by the ACA could cause serious distortions and damage in insurance markets. — Timothy Jost, JD

So given that a) guaranteed insurance issue is popular, and b) American insurance companies aren't charities, Congress may be in for a long stretch at the drawing board.

I think the individual mandate and guaranteed issue are two sides of the same coin and will not go away. People in Congress don't really want to get rid of them. — J. Mario Molina, MD

So again, we see realities of the industry working against a quick repeal and replace.

Should hospitals continue to prepare for a shift to value-based care?

  • Our sources say: Yes, absolutely.
The idea of healthcare value is an old one. In fact, CMS has been looking for ways to define, measure, and promote it since the establishment of Medicare in the 1960s.
The quality movement is one area of healthcare that has generally enjoyed bipartisan support.

My sense is that the CMS Innovation Center is aligned with both sides of the aisle. — Mike Thompson, President, National Alliance of Healthcare Purchaser Coalitions 

The ACA brought value into the spotlight by establishing and funding the Center for Medicare and Medicaid Innovation (CMMI), which piloted ACOs, bundled payments, and other value-based care initiatives.
Applying these ideas at the state level in order to improve access and quality has been popular across party lines. In fact, former Senate Majority Leader Tom Dacshle (D-S.D.) and former House Speaker Newt Gingrich (R-Ga.) coauthored a 2015 report in support of CMS innovation grants.
And even if the ACA were repealed in full (which seems unlikely), the value movement would likely be buoyed along by other laws. Notable examples include MIPPA (which forms the legislative foundation of PQRS) and MACRA (which repealed the "doc fix" in favor of a yet-to-be-finalized value-based reimbursement scheme).
So as your organization braces for change, we suggest keeping those quality initiatives on track. Do what's best for patients, and unlike a presidential candidate, you'll always win.

Could this upheaval actually be a good thing for healthcare reform?

  • Our sources say: It's up to us.
The new administration presents opportunities as well as challenges. But in order to seize those opportunities, providers, patient advocates, and professional organizations need to be part of the process. 

Clearly Obamacare will undergo significant changes. As providers, we have an opportunity to shape and improve policy that benefits our patients and communities rather than insurance companies. Let's hope for and work to create a better healthcare system for all Americans. — Tom Sugarman, MD, Vituity Partner, Past President of California ACEP 

Advocacy and policy work are something CEP and its providers take seriously. We have a long history of working with our professional organizations and lawmakers to improve care.

The most important element of advocacy is to be present at the table. Vituity has invested heavily in advocacy so we can have a voice at the table that will be heard. — Bing Pao, MD 

So what should our goals be? Well, to start with, we need to find solutions that work for both sides.

All the historically enduring social benefit programs of the past 100 years were passed with bipartisan support, even if it was modest (usually it was a minority of Republicans going along with a Democratic plan — Social Security, Medicare, Medicaid). The Affordable Care Act famously fell short of that, so the rancor that was supposed to happen in the drafting of the bill, ending in compromise, never got resolved and continues to this day.
The best thing for our specialty would be that there is a reasonable degree of bipartisanship so that we don't go through lurching reversals every time the parties switch control of the houses of government. — James Nelson, MD

So now that you've heard some expert opinions about where we're headed, what's yours? Comment below to share (keeping it on topic and respectful, please).