Pinnacle: The Uncertain Future of Healthcare Reform

Congressional Republicans who want to undo the Affordable Care Act haven't had much luck so far, but not for lack of trying. House and Senate repeal/replace attempts have occupied much of 2017. Now, with efforts in limbo as both bodies recess, EMS leaders are no closer to getting a final answer than they were before the 2016 election of Donald Trump.

Fitch & Associates' Roxanne Shanks ran down the current landscape Wednesday at the Pinnacle EMS conference in a session titled "The Uncertain Future of Healthcare Reform: What EMS Leaders Need to Know." She painted a gloomy picture of the ACA in which applications to provide health plans through the Act's exchanges have plunged by 38% in a year, more than 1,000 U.S. counties have just one provider to choose from, and 47 rural counties actually have none. Premiums are rising, and Americans are losing choices and losing coverage. "The status quo," she observed, "is not working."

Among the big issues: Rates and plans are due next month for exchange participants, and they're uncertain if cost-sharing reduction (CSR) payments will continue. A court prevented Trump from ending them unilaterally, but his administration is proceeding on a month-to-month basis, leaving insurers wary. As well, individual and employer mandates aren't being enforced, and DSH (disproportionate share hospital) allotments, which the ACA scaled down as more Americans theoretically gained coverage, may now be axed by Congress. 

In short, a hostile administration is setting an unfavorable landscape that poses too much "who knows?" for many insurers. How that will shake out once Congress gets back to work is anybody's guess.

Shanks also addressed potential value-based payments for EMS, which remain a possibility despite the GAO's discovery of problems with that system applied to hospitals. Support for improved quality at lower cost remains high and bipartisan, and three EMS organizations--the American Ambulance Association (AAA), Association of Air Medical Services (AAMS) and Association of Critical Care Transport (ACCT)--have floated draft legislation to help expedite the transition. 

Another rule change may result in some EMS mileage claims being denied. The Medicare locality rule requires transport to the nearest appropriate facility, but MACs (Medicare administrative contractors) haven't always limited it. Starting next month, they will be able to define "loclaity." Per EMS law firm Page, Wolfberg & Wirth, "This means that some MACs may not recognize any 'localities' in their jurisdictions, and others may provide specific locality determinations for ambulance coverage." For more on the subject from PWW, see https://www.pwwemslaw.com/news/new-medicare-“locality-rule”-may-lead-denied-mileage-claims.