How should hospital and physician leaders plan for the future now that President Donald Trump and the Republican majorities in Congress have failed at their initial attempt to repeal and replace the Affordable Care Act? Much confusion remains about what comes next, but some clarity is emerging.
Here’s what we now know that we didn’t before the American Health Care Act could not get enough Republican votes to pass the House:
- Only 17% of Americans supported the AHCA, per a Quinnipiac University poll.
- Any concession to get more conservative House members to support a bill will alienate more moderate Republican House members and senators.
- Trump does not know enough details about healthcare to successfully advocate for a bill.
- A Kaiser Family Foundation poll this week found that:
- 64% of Americans thought the failure of AHCA was a good thing.
- Three-fourths thought Trump should do what he can to make the ACA work.
- One-fifth thought Trump should make the ACA fail.
- 61% will hold Trump and the Republicans accountable for any problems with the ACA moving forward.
- It is unlikely that any repeal bill will be approved by the House and the Senate in the foreseeable future.
Given the above bullet points, it might seem logical that the Republicans and Democrats would work together in a bipartisan way to improve the ACA. The White House even invited Ezekiel Emanuel, who helped write the original bill, to share his thoughts on the way forward. Even though a bipartisan approach seems highly unlikely given the political climate, there are some obvious improvements that could be implemented:
- Republicans could drop the pending lawsuit that threatens the legality of cost-sharing reduction payments that the federal government sends to insurers to ensure that lower income Americans can have smaller deductibles.
- The Republicans could enforce the individual mandate so that more younger Americans buy health insurance.
- The administration could grant states more flexibility to increase competition and decrease costs. (Alaska has already used such an approach to create a reinsurance pool.)
- The CMS could continue to experiment with value-based payment models, implement MACRA, and expand the bundled payment programs, as former Centers for Medicare & Medicaid Services acting administrator Andy Slavitt suggested in a recent op-ed for USA Today.
However, a bipartisan approach to improving the ACA does not seem likely. In his remarks after the failure of the AHCA, Trump said “the best thing we can do politically speaking is let Obamacare explode. It’s exploding right now.” Although most experts do not agree that the ACA is failing, as an NPR article points out, the Trump administration can undermine the ACA without Congress passing any new laws. Existing and possible examples include:
- The administration did not air already-paid-for television ads encouraging young people to sign up for insurance in 2017.
- The administration can cut the budgets of agencies that are charged with administering the law.
- The CMS administrator can give state waivers to avoid some of the ACA’s provisions.
- Department of Health and Human Services Secretary Tom Price has criticized the Center for Medicare & Medicaid Innovation—which supports new models of care and payment—and he has delayed the expansion of bundled payments for hip and knee replacement surgery.
- Decisions by HHS can reassure or disappoint insurers that have to decide by this spring if they will participate in the ACA exchanges.
- Donald Berwick, who directed the CMS under President Barack Obama, wrote in a piece for The New York Times that the Republicans will try to sabotage the ACA.
Hospital and physician leaders should plan for the ACA to continue to be the law of the land, and they should recognize that the Republican administration will continue to oppose it.
They should be ready to deal with the fallout of unstable state insurance exchanges if the administration does not do enough to reassure insurers. Just this week, the largest insurance company in Iowa announced that it will not offer ACA insurance in 2018. The American people have grown used to the benefits they enjoyed under the ACA, and any attempts to undermine key provisions of the law will be met with widespread opposition.
Kent Bottles, M.D., is a lecturer at the Thomas Jefferson University School of Population Health and chief medical officer of PYA Analytics.