Because of the health care policy work I have done over the years, I often get asked about what to expect from Capitol Hill and from federal policy makers in D.C. Since the surprise election results in November, the most common questions revolve around what impact the Trump administration is likely to have on the delivery system reform work done since the passage of the Affordable Care Act (ACA).
Will the ACA get repealed? And if so, what will that mean? Will the movement away from fee for service and toward payment for quality and satisfaction slow down or stop? Will Accountable Care Organizations (ACOs), bundled payments, and the testing of other new payment models all come to a halt, just as we were gaining confidence that this might be the answer to lower health care costs? Will the move toward population health (that we hoped would improve our health care system) stall or evaporate?
While much uncertainty remains, events since the election have given us some clues to answer these and other questions.
Let’s address the ACA. It’s important to recognize that the ACA cannot be repealed completely for at least two reasons. First, it does not even exist as it was passed, having undergone several changes, including adjustments and exemptions. Second, parts of the bill would require 60 votes in the Senate to repeal, and those votes are not available to the party seeking repeal.
Yes, parts of the bill could be changed significantly with only Republican votes. However, the reality is that many changes would have occurred even if Hillary Clinton had won the election; there are elements of the current law that are not working and that both sides acknowledge need to be fixed, such as state individual insurance exchanges.
There also are parts of the ACA that neither party would like to see rescinded, which are unlikely to be removed in a new law – for example, losing insurance for preexisting conditions.
From the standpoint of providers, the most notable aspect of the current discussion is that proposed changes have largely been limited to addressing areas of insurance reform. This has potential impact on who is covered under a revised plan. In the meantime, the important work of delivery system reform – the elements of the ACA that providers care the most about (and that will have the most impact on their careers) – have been left untouched. There are strong signs that this will remain the case and that this important work will continue.
What are those signs? First of all, neither the “repeal” bill passed by the House nor any of the bills considered by the Senate made any mention of interrupting any of the important work being done by the Center for Medicare & Medicaid Innovation (CMMI), the part of the Centers for Medicare & Medicaid Services created by the ACA to develop and test alternative payment models (APMs), like accountable care organizations, bundled payments, etc. If successful, this work will improve quality while lowering the growth of health care costs and may save a health care system that, if unchecked, will create a crushing financial burden that threatens the Medicare Trust Fund. It also is a strong and clear sign that the CMMI continues its work today under the same effective leadership that first created excitement about its potential to improve the delivery system.
But probably the clearest sign that delivery system reform will continue was the strong bipartisan support shown in the passage of the Medicare Access and CHIP Reauthorization Act (MACRA) in April of 2015. This landmark piece of legislation creates a pathway that moves the entire health care system away from fee for service and toward payment models that will reward providers for innovations that will lower the cost of care, eliminate waste, improve safety, and achieve better outcomes. It puts in place a plan that will use APMs to offer providers the incentives to create care models that may be the salvation of our health care system. In the long run, isn’t this what matters the most?
Politicians in Washington can’t save our system. They can create or remove entitlements or support one segment of the population at the expense of another. But, in the end, they are only moving dollars around from one pocket to another, rearranging deck chairs on the Titanic of the American health care system.
The reality is that the only thing that can save our health care system is to lower the cost of care. And we all know that, as providers, only we can do that. SHM will be helping its members lead the way, providing educational content, training, advocacy, and policy leadership.
It will be up to the nation’s caregivers to reform the delivery system in a way that is sustainable for our generation and generations to come. We continue that work today, and I see no evidence that anyone on Capitol Hill wants us to stop.