Let's Add "Repair" to Repeal and Replace

Thursday, March 9, 2017 | Larry Sobal

 

In the words of Winston Churchill, “Now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning.” That may aptly describe the release of the long-awaited plan, known as The American Health Care Act, which intends to repeal and replace the Affordable Care Act (aka ACA and Obamacare). There are a number of notable changes being recommended, as well as some continuations. Right now it appears that the new plan’s unveiling sets the stage for a bitter and consequential debate over the possible dismantling of the ACA, arguably the most significant health care law in a half-century.

The details of the 128-page proposal were released without any Congressional Budget Office (CBO) score, a sign that Republicans may be worried about the fallout once Americans understand how many people could be affected by changes in coverage. While Republicans had long argued their plan would give consumers more flexibility, the authors of the bill stated that it was not necessarily designed to cover more people than the ACA did. The CBO score is expected to reflect that reality, which Republicans stated is the reason it was not part of the bill's initial unveiling. It’s important to note that when the original language of the ACA was first marked up in the House, it was done without a score.

As expected, the release triggered immediate criticism from those who support the current legislation, including some Republican congressmen who called it “Obamacare 2.0” and “Obamacare lite.” Many others criticized the lack of transparency involved to have gotten it to this point. However, I’m guessing some of the secrecy to date came from Republican leaders trying to avoid a repeat of what recently occurred, when an outdated draft was leaked and quickly attacked. More likely the secrecy reflects the high stakes surrounding the effort to rewrite the ACA, a top priority of President Donald Trump, who campaigned on “repeal and replace.” Republican leadership is caught in the middle between Democrats (along with some Republicans) who are strongly against anyone losing their current ACA health care coverage and conservative members of the GOP caucus who want a wholesale repeal of the ACA.

The overall GOP intent to do something with the ACA is obvious, but the method for accomplishing a change has thus far been very confusing. There have been a host of different opinions ranging from immediate repeal to a process that could take years. Individually offered Republican proposals have run the gamut from those committed to fiscal conservatism to those reflecting a fear of the consequences of voting for legislation that reduces insurance coverage. Whether or not the American Health Care Act unifies the party will be interesting to watch.

In President Trump’s recent address to Congress, he did offer five principles for Congress to follow in their efforts to craft new legislation:

1. Ensuring people with pre-existing health conditions are guaranteed "access" to health insurance, "and that we have a stable transition for Americans currently enrolled in the health care exchanges.”
2. Giving people who buy their own health coverage tax credits and expanded health savings accounts to help pay for their coverage, as well as flexibility about the design of their plans.
3. Give states "the resources and flexibility" in their Medicaid programs "to make sure no one is left out."
4. Legal reforms to protect doctors and patients "from unnecessary costs" that drive up insurance costs, and to bring down the price of high-cost drugs.
5. Creating a national insurance marketplace that allows insurers to sell health plans across state lines.

While Trump has expressed confidence in the ability of his party to pass comprehensive health care reform legislation, Congressional Republicans might not be as optimistic as they encounter factional divisions, criticism from voters and partisan opposition from Democrats.

Interestingly, there are very conflicting public polls regarding the popularity of the ACA. On one hand a recent poll from the Pew Research Center shows that the ACA's popularity is soaring and has hit its highest point since it was passed with 54% of respondents in Pew's survey saying they approve of the law, and 43% disapproving. This is better than the 48% approve, 47% disapprove margin from December 2016.  But a survey of actual ACA customers released recently paints an entirely different picture. It found that just 22% of the 44,200 enrollees polled rate their health plan as good to excellent. That's down from 77% who gave their plans high marks last year. The reasons for the sharp declines include: higher premiums, worse service and lack of choice. The survey, conducted by Black Book Market Research, found that 96% reported a decline in customer service support, 90% noted premium increases, 80% said their plans had narrower provider networks, and 77% said their plans' benefits had been trimmed. Nearly two-thirds (61%) complained about lack of competitors in their market.

Where does that leave us?  House Speaker Paul Ryan wants committees to mark up and advance an ACA repeal bill as soon as possible and for Congress to pass it through the expedited budget reconciliation process on a straight party-line vote before the Easter recess in early April. If that happens, then it’s on to the Senate for their kick at the can.

We need a thoughtful, long-term view.

But Democrats, health care industry groups, and the general public have only now gotten a chance to see any details. And other Republicans repeatedly have promised to pass a repeal-and-replace bill through an open and inclusive process offering everyone plenty of time for input, unlike what Republicans claim was the backroom process by which Democrats passed the ACA.

When I think of what a “drain the swamp” process would look like going forward, I propose something as simple (and uncommon) as a truly transparent and bipartisan process. One that will, and should, take time.  Let’s make all the legislative conversations accessible to the public on TV to expose the good (and bad) ideas, put them out in the open for consideration, and see who is (or isn’t) capable of having an open-minded, bipartisan discussion. In addition, let’s add the word “repair” to the dialogue to recognize that there are aspects of the ACA that most agree should continue in some form.

There is no precedent for Congress to reverse a major social program of the magnitude of the ACA once it has taken effect and reached millions of Americans. I understand that a final output of a “new and improved” health care legislation will not please everyone, but the stakes demand that we utilize a transparent and bipartisan approach. Our history of not doing so doesn’t seem to have worked very well. We need a process going forward that has enough bipartisan support to sustain programs over time. In other words, we need a thoughtful, long-term view. The U.S. health care system and the people it serves deserve that.

 

Illustration: Lee Sauer

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Larry Sobal is Executive Vice President and a Senior Consultant at MedAxiom. He has a 35-year background as a senior executive in medical group leadership, hospital leadership and health insurance. Larry consults, writes and presents on topics relevant to transforming physician practices and health systems. His weekly blog post comes out on Thursdays and can be accessed at www.medaxiom.com.

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