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December Cover Story: Health Reform Remains Unclear Heading Into 2018, Part 1
One year ago, First Report Managed Care asked a group of experts to analyze how Donald Trump’s unexpected rise to the presidency would impact the US health care system in the coming year, under a new president. Twelve months later, one could argue that, in many respects, we still do not know. Part of the reason is that political distractions within the Administration have derailed some of the momentum that was building behind the effort to repeal the ACA.
The question is: has a health care strategy emerged that is difficult for most to see? Or have we essentially been running in place all year (or worse, going backwards)? And regardless, where are we headed? We asked our experts to cut through the fog and give us a clearer picture of the state of the United States health care system going into 2018.
One thing that is clear to all: the Administration is taking the only path it can at this point—the nonlegislative route.
“The strategy is to modify the current health care model even in the absence of congressional action,” David Marcus, director of employee benefits, National Railway Labor Conference, said. “This can be done by regulatory changes or by simply defunding health care programs.”
F Randy Vogenberg, PhD, RPh, principal at the Institute for Integrated Healthcare, noted that while doing an end-around Congress is the primary strategy, the Administration is looking to make “specific legislative language changes when possible, such as [in] the tax reform bill.”
In early December, that bill was headed for Joint Conference Committee and then to the President to sign into law; it includes a repeal of individual components in the Affordable Care Act’s (ACA) individual coverage mandate—the first major legislative change to the ACA in 2017.
“Dismantling the ACA Piece by Piece”
Norm Smith, director of payer research for Research America, Inc, noted that he believes Congress has not been President Trump’s only roadblock.
“With the limited guidance coming from CMS, the President has utilized executive orders to roll back the ACA, to [both] annoy Obama holdovers and respond to his base,” he said.
Many have pointed out before that the ACA is not going anywhere. Editorial advisory board member Barney Spivack, MD, national medical director of Medicare case & condition management at OptumHealth, said he continues to believe that is the case, but also worries about efforts to undermine the law. He acknowledged that eliminating government subsidies has “significant negative consequences, for the public and insurers.”
Michael S Sinha, MD, JD, MPH, a Boston-based health services researcher, described the administration’s strategy as a “dismantling of the ACA piece by piece but under the guise of something else.” He added that he worries about efforts to conceal ACA changes in the tax bill, noting that it “has garnered less public outrage than we saw with the [ACA repeal] bills.”
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UNSURPRISING STRATEGY
Melissa Andel, health policy director at Applied Policy, a health policy and reimbursement consultancy, said she is not surprised by the moves the Administration has made.
“Once you get below the surface chaos, many of the proposals that we have seen so far have not been out of line with what one would expect from a Republican administration generally,” she said, citing three examples:
• The proposed rule outlining requirements for qualified health plans in 2019. “CMS has proposed to grant states more flexibility in selecting benchmark plans, and granting more flexibility to states that are using the federal exchange platform,” explained Ms Andel. “These proposals are in line with general Republican support for delegating more authority to the states to regulate insurance products.
• A recent proposal regarding Medicare Part D included stipulations designed to give Part D plan sponsors the ability to adjust formulary coverage more quickly to keep up with the availability of generic substitutes and therapeutic alternatives. Such efforts “are commonly seen on the commercial side,” and generally supported by conservatives.
• Medicare Advantage enrollment continues to grow, driven mostly by new Medicare beneficiaries. “Republicans have historically supported [this] benefit.”
Still, the ACA exchanges remain a place where confusion and instability reign.
“The main open question at this point seems to be what impact the rhetoric about the ACA and marketplaces has on enrollment,” explained Ms Andel. “Open enrollment has been cut by 6 weeks, and outreach has been dramatically reduced. Surveys have shown that many people erroneously believe that the ACA has been repealed. It remains to be seen how this will impact enrollment and the risk pool, and how off the actuarial projections for 2018 will be.”
One wonders how things might have played out if federal subsidies and the designated enrollment period were left in place.
“In 2017, we actually saw that health insurance plan margins on marketplace plans were stabilizing, and [several] had turned a profit” said Ms Andel. “From the outside, it looked as if the plans had started to better predict the medical costs of enrollees and price premiums accordingly. But it isn’t clear whether or not the turmoil of 2017 has irreparably damaged the marketplaces.”
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