Editor’s note: This story is part of the CDT’s Business Matters special section.
By now, the numbers are well-known. About 20 million Americans gained health insurance through the Affordable Care Act, the 2010 legislation that became the centerpiece of President Barack Obama’s domestic policy. For Republicans to fully “repeal and replace,” they’d need a 60-vote supermajority in the Senate. But reconciliation, which is immune to filibuster, is the more realistic route, one that can gut certain provisions of the ACA.
Yet “replace” is where the bemusement begins. Dismantling the ACA, even with a Republican-controlled Congress and a Republican president, will be as difficult as disentangling the snake from the staff. Still, a consensus has not been reached.
“I think it changes on a daily basis,” said Dennis Scanlon, the director of the Center for Health Care and Policy Research at Penn State and a professor of health policy and administration, on the future of the ACA. “It’s hard to separate fact from fiction.”
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Democrats say a repeal could not only strip about millions of Americans of their coverage, but also cause chaos in the insurance markets. During a January news conference, Sen. Chuck Schumer, of New York, the Senate Democratic leader, described the agenda as “Make America Sick Again,” a play on the popular phrase used by President Donald Trump during the 2016 presidential campaign.
According to the nonpartisan Congressional Budget Office, 18 million people could lose their insurance within a year if major provisions of the ACA are repealed, the New York Times reported.
Republicans counter that the ACA’s economics would ultimately hurt the country. Premiums are increasing, they argue, and having wealthier Americans pay more to help fund subsidies for those who purchase coverage through government programs is unsustainable. High deductibles under the ACA, meanwhile, mitigate the promise of having affordable coverage in the first place.
Repealing the ACA is a top priority for the president. In January, Trump told Congress to undo the act and find a replacement quickly, calling the ACA “a catastrophic event.”
By the numbers
Locally, experts say the future of health care will be tied up, like the rest of the nation, in the future of the ACA.
“This patient population that is served by the ACA is still going to need to be served,” said Matt Nussbaum, the associate vice president of regional operations with Geisinger Health System. “So whatever the product of a Trump administration is, we want to be positioned to serve that population. How it gets paid for — I think that’s the piece that people will need to figure out.”
According to the Economist, the uninsured population among low-income whites fell from 25 percent in 2013 to 13 percent in 2016, highlighting a key beneficiary of “Obamacare” — the same population that voted in large numbers for Trump.
The gap between the insured among the college-educated and those with a high school degree decreased sharply in 2014, the first full year of the ACA. Minorities, immigrants and the poor saw the largest gains in coverage, a New York Times analysis found, with part-time workers getting covered at higher rates than full-time workers.
After 2016’s Open Enrollment period ended, the Department of Health and Human Services reported about 12.7 million consumers selected plans or were automatically re-enrolled across the country.
“As a general principle, it is important for people to have access to care,” said Tom Charles, vice president of system development and chief strategy officer at Mount Nittany Health. “So whatever happens going forward, it would be my hope that those changes make it easier for people to have access to care and we don’t make it more difficult going forward.”
According to the Department of Health and Human Services, about 479,000 Pennsylvanians gained coverage as a result of the ACA. Since 2010, the state’s uninsured rate, meanwhile, fell by 37 percent.
But the future of healthcare in the region will still hinge on what happens nationally. Trends, such as a move away from fee-for-service models to more value-based models, technological advancement and continued consolidation, will shape the industry at all levels, experts say.
Nussbaum said regional systems are focusing on keeping care local, whatever the changes may be nationally.
“If it means the payment model gets pushed back to the states as opposed to a federally driven one, we feel like we have a good relationship with Harrisburg and we’ll figure out a way to work with them to optimize a payment model,” he said. “We’re always striving to reduce fat in the system. Keeping care local is a big part of that.”
Shifting from ‘volume over value’
Part and parcel of rising healthcare costs, some of the highest in the developed world, are the unforgiving payment models that have defined the industry for decades.
“Fee-for-service, I think, is in many ways responsible for the runaway healthcare costs that we have had,” Scanlon said. “It’s been volume over value.”
But that is changing, he added, partly due to the ACA.
“Traditionally in health care we’ve had fee-for-service,” he continued. “The past eight years, and most recently in the past couple of years, have really moved toward paying less based on fees and more based on outcomes and population-based needs.”
Scanlon explained that population-based payments, the current alternative to fee-for-service, are analogous to having a home, a budget and day-to-day expenses.
“A population-based payment is an idea where instead of everything little thing you do, you get paid, we pay you sort of a base amount per person whom you have to manage the care for,” he said. “All of sudden now you have to think about managing a pot of money to provide care for a population of patients, and everything you do clinically — every doctor visit, every hospitalization — you’re not going to necessarily get a new payment. You’ve got to manage that global budget.”
Yet the fix, of course, is not easy. Multiple solutions have been offered; different versions exist; reaching a political consensus can be a crapshoot. Finding, implementing and agreeing upon an alternative can take years.
Scanlon said he thinks the trend away from a fee-for-service model will continue, but also mentioned uncertainty reigns as the new administration settles in and makes changes.
Tom Price, the secretary of Health and Human Services, for instance, has criticized The Center for Medicare and Medicaid Innovation, created from the ACA, as interfering in the doctor-patient relationship.
While the center and others have looked for ways to track and analyze outcomes, Price has pushed back. According to the Atlantic, the new Department of Health and Human Services and the Centers for Medicare and Medicaid Services “could roll back any potential patient gains or data gleaned from these projects.”
But the proof still exists in a rather murky pudding.
“It’s very difficult to speculate, quite frankly, until the details, the intent become clearer,” Charles said. “I think at that point it will be much easier to know what it is that is going to be retained, what is going to be changed and consequently what the impact is going to be for us.”
In 2016, Pennsylvania’s Department of Human Services echoed the shift away from fee-for-service. It announced its Medicaid system is shifting from a quantity of care focus to a quality of care focus, targeting approaches that reward healthcare organizations for providing “high-quality care” over just providing services for a fee.
Geisinger’s health plan was recently chosen as one of six to continue with negotiations to offer services through HealthChoices, the state’s medical assistance program. According to a release, the system serves more than 179,000 Medicaid members.
“We’re excited for the opportunity to continue working with DHS and the HealthChoices program,” said Steve Youso, chief executive officer at GHP, in a statement. “Our managed Medicaid plan, GHP Family, helps to ensure that Pennsylvanians have access to quality care, so we’re happy to partner again with DHS and the HealthChoices program.”
Nussbaum said improving how patients are educated will go a long way in cutting down costs for everyone.
“I don’t think there’s any one right answer as to how we’ll get there,” he said. “I think systems are going to have to look at how they can shift away from that to more of a bundled-payment model. I think that’s where medicine is really going, is trying to manage as much as possible on the outpatient side and avoid admissions and re-admissions.”
But ultimately, experts say, the responsibility is shared among all parties — patients, providers and policy makers. Therein lies the challenge.
“The bottom line is that this remains a pervasive problem regardless of who is in the administration, Republicans or Democrats,” Scanlon said. “Some would argue whether or not the ACA was successful in curbing spending. But the bottom line is that everybody believes that healthcare is really, really expensive and ultimately we need to figure out how we’re going to afford it as a society.
“And that is not going to change.”