My Take: It’s Time for a Fresh Start on U.S. Health Reform

It appears Republican Senators are still trying to resolve their differences about the path forward for their Better Care Reconciliation Act: some think it doesn’t go far enough in repealing the Affordable Care Act and others think its Medicaid cuts will hurt their states. Speaker McConnell is expected to schedule a vote this week to Repeal the ACA, replacing it in two years with something else.

And Democrats in the Senate have vowed to cooperate with their GOP counterparts but only IF Repeal is off the table and their pre-conditions are met.

Partisan bickering about healthcare is not new. For the past 70 years, Democratic administrations have advanced reforms aimed at expanded coverage and Republican have sought to limit the federal government’s role. And in each episode, trade groups representing doctors, nurses, hospitals, drug companies and health insurers have sought to influence the outcome.

In the Truman administration (1945-1953), two efforts to pass universal coverage, assailed as “socialized medicine” by the American Medical Association and Republicans, failed. But it succeeded in passing with the Hospital Survey and Construction Act of 1946 (commonly known as the Hill-Burton Act) which led to hospital construction in every community. 

In the Eisenhower administration (1953-1961), Republican healthcare reforms were limited; modernization of military medicine (1956) was the major accomplishment of Gen. Eisenhower.

In the Kennedy administration (1961-1963), Democrats supported the legislative foundation for the Medicare program against fierce opposition of the AMA, Republicans and Blue Dog Democrats.

In the Johnson administration (1963-1969), with a super-majority of Democrats in both houses of Congress, the Great Society program marking the start of Medicare and Medicaid programs passed July 30, 1965.

In the Nixon administration (1969-1974), the National Health Insurance Standard Act, which mandated employer insurance coverage, failed (1971) but the Health Maintenance Organization Act of 1973 passed which laid the ground work for managed care. But it competed against fierce opposition from Sen. Edward M. Kennedy’s Health Security Act, which called for a single federal payer that would provide comprehensive health coverage for all Americans.

In the Ford administration (1974-1977), Republicans focused their attention on recovery from Watergate, “our long national nightmare”. Their only major legislative accomplishment was passage of National Health Planning and Resources Development Act of 1974 which reduced duplication of healthcare facilities via Certificate of Need procedures in each state. Although the CON mandate was repealed in 1986, 36 states and the District of Columbia still operate CON programs today.

In the Carter administration (1977-1981), healthcare took a backseat to the deep recession, though candidate Carter had campaigned for universal coverage.

In the Reagan administration (1981-1989), legislation passed that reduced Medicare costs spending by changing its reimbursement methodologies and the addition of aggressive anti-fraud measures. But in a departure from Republican dogma against expansion of government health programs, it also passed the Medicare Catastrophic Coverage Act of 1988 which expanded Medicare coverage for outpatient drugs and long-term care funded entirely by Medicare beneficiaries’ premiums and a surtax on wealthier beneficiaries.

In the George H.W. Bush Administration (1989-1993), Medicare enrollee pushback against higher premiums led to repeal of Medicare Catastrophic Coverage Act 17 months after its passage. The most notable health reform of this administration was passage of limitations on physician self-referral (Stark 1) which faced limited opposition in Congress.

In the Clinton Administration (1993-2001), after 12 years of Republican occupancy of the White House, health reform took center stage again as a priority. The focus: managed competition, a mechanism whereby health insurance would be regulated by regional health alliances in each state that would require employers to provide a minimal level of coverage and pay 80% of the premium for employees. The American Health Security Act of 1993 was opposed by health insurers and had split support among Democrats. After its failed to garner the support of key Democrats, the AHSA was pulled a year later, but health reform legislation continued including the Health Insurance Portability and Accountability Act, expansion of the Stark physician self-referral law (Stark II), and the State Children's Health Insurance Program.

In the George W. Bush Administration (2001-2009), recovery from 9/11 was the focus, though passage of the Medicare Drug Improvement and Modernization Act of 2003 added a prescription drug coverage benefit, Medicare Part D, to the program over Democratic opposition.

And in the Obama Administration (2009 - present), healthcare reform was a high priority stoking partisan passions among opponents around “death panels”, “socialized medicine” and “government run healthcare”. The Patient Protection and Affordable Care Act became law March 23, 2010, and was affirmed by the Supreme Court June 28, 2012 in its ruling in National Federation of Independent Business v. Sebelius.

So, for more than 70 years, our political system has struggled with a coherent, comprehensive healthcare policy. The political parties have consistently advanced their views for and against government involvement even as healthcare grew to be 28% of total federal spending. In retrospect, the current debate about Repeal and Replace vs. Fix and Repair is another chapter in the same book. The same questions keep popping up:

  • Is healthcare insurance coverage a right or privilege?
  • How do we control health costs, especially those born by government?
  • What is the government’s role?

In 2009, I was involved in an effort to bring industry leaders and policymakers together address the issues facing our health system: unsustainable costs (increasing at 6% per year), variable quality (wide variability in utilization and outcomes) and limited access to healthcare for one in six of our citizens who lacked insurance coverage of any kind (leading to avoidable death and costs). Under the oversight of the White House Office of Health Reform, representatives of hospitals, drug and device manufacturers, health insurance companies and physicians met to develop recommendations to protect what works well in our system and fix what doesn’t. That effort produced a list of suggestions some making their way into the Patient Protection and Affordable Care Act (later abbreviated as the Affordable Care Act/ACA).

The ACA has notable flaws that are widely known. But setting aside politics. its underlying assumptions still seem reasonable:

  • The majority of Americans favor a private system over one run by the federal government. 
  • Access to health insurance for those without can reduce long-term health costs.
  • To reduce waste and improve health, the incentives in the system for providers should change from fee for service to value.
  • And states should play a larger role in administering and regulating the system of care.

But then it got tricky in a highly charged partisan climate and more complicated as trade groups representing their constituents flexed its influence muscles. Each advanced the notion that other sectors were more wasteful and complicit in its shortcomings than their own. Each skillfully made their case to policymakers and the public: drugs and devices save lives and operate risky businesses where there are more strikeouts than home runs, health insurers are the guardians of cost containment and the only sector serious about the challenge, hospitals operate to deliver care that’s needed but unfairly reimbursed and physicians do God’s work selflessly. All think government regulation is necessary, but counter-productive if it infringes on the business interests of their members. So, changes come slowly, and laws are rarely comprehensive. Case in point: though the Affordable Care Act addresses changes in how providers are organized and paid, how physician practice is to align with evidence-based recommendation, how avoidance errors and unnecessary care is addressed and much more, the current debate about Repeal and Replace is focused almost exclusively on health insurance coverage for those previously uninsured, its cost and how insurers are regulated. Important but not the complete scope of the ACA.

Concepts like evidence based care, comparative effectiveness, bundled payments, accountable care organizations, primary-care medical homes, value-based purchasing and others don’t attract media coverage nor legislative interest beyond industry insiders and the trade groups themselves. That’s where we are today: focused on coverage more than care amidst seemingly intractable partisan positions and a public’s that’s strongly divided about the right path forward.

Is it time to take a fresh start at health reform in our country? I think yes. Is it conceivable members of Congress will produce a new product in the next two years that’s fiscally sound and widely accepted as an improvement Speaker McConnell promises? That’s possible, but it requires fresh input. Will a new vision of health system transformation that recognizes clinical innovation, fiscal restraint and the larger role consumers will play evolve? Maybe, but not without fresh thinking from those not encumbered by election cycles and earnings per share.

What if instead of Congressional hearings that serve as pseudo-media events, a blue-ribbon task force of Governors, employers and citizens designs the system of health for our future, and the mechanisms necessary to govern and fund it appropriately? What if the focus of its work is find creative ways to manage the 10% in our population who consume 68% of our costs and ways to keep the 70% well? What if the data about which diagnostic tests, procedures, drugs and care management programs work and what they cost best becomes widely accessible?

What if terms like waste, fraud, abuse, quality, safety, access, value, outcomes and others were defined and measured consistently across all sectors? What if the policy framework that’s created balances health and social services and personal accountability with government oversight? And what if implementation of its recommendations was not timed to benefit either party’s chances in an election?

It’s easy to blame our politicians: we elect them, but we don’t trust them. It’s easy to complain about runaway health costs but pay no attention to root causes and the responsibility we collectively bear for our unhealthy lifestyles and lack of engagement in decisions impacting our care. It’s easy to watch the Washington recrimination game and hear pundits who think know better than anyone else what’s best for “the American people.” Meanwhile, the health system is underperforming, impacting everyone, not just for those who lack coverage.

Our $4 trillion health system is expensive and flawed. It needs modernization, transformation and reforms. Is that possible in the current political environment? It’s unlikely. We need to hear from new voices with fresh ideas. If that’s possible, sign me up to help. But complaining about DC isn’t an option. It takes a fresh start.

That’s my take.

Paul

P.S. Are ACOs’ underperforming? Are they worth the effort? More than 800 hospitals and medical groups have set up ACOs. It’s one of the ACA’s demonstration programs aimed at lowering Medicare cost growth by allowing providers to share in the savings they produce by more effectively coordinating enrollee care. In a study released last week, medication adherence of Medicare enrollees with diabetes and heart disease in the Medicare Shared Savings Program (accountable care organizations) was compared to enrollees in traditional fee-for services relationships.  After analyzing comparing the two groups over a 5-year period, the researchers concluded: “Through its third year of operation, the Medicare Shared Savings Program has not meaningfully increased the use of or adherence to medications that improve outcomes for patients with cardiovascular disease or diabetes.” “Association of Changes in Medication Use and Adherence with Accountable Care Organization Exposure in Patients with Cardiovascular Disease or Diabetes” J. Michael McWilliams, MD, PhD; Mehdi Najafzadeh, PhD, MSc, MA; William H. Shrank, MD, MSHS, 4Jennifer M. Polinski, ScD, MPH6 JAMA Cardiol. Published online July 12, 2017. doi:10.1001/jamacardio.2017.2172. Though this study concludes ACOs are not getting better results on medication adherence, it does not mean ACOs are not delivering value to patients and the ACO sponsors. Rather, it suggests that Medicare’s attribution methodology might obviate the potential for greater savings. My take: the ACO value proposition is still a work in process!