Our Short-Sighted and Divided Country Looks for an ACA Replacement

We have short attention spans and shorter memories. That serves politicians well but it makes bad policy.

Say, for example, you decided to run for President of the United States but you pulled a really stupid college-style prank, like plagiarizing someone else’s work, that makes you ethically ineligible for the presidency when the story gets out.  If you’re lucky, voters and even journalists who investigate the backgrounds of candidates might well forget your indiscretion a few decades later and you could end up, say, in the  White House a heartbeat away from the Oval Office.  You just never know in politics. Yesterday’s bum steer could end up today’s political sacred cow.

Take Obamacare. Please.

Way back in 2010, the public furor over the passage of the Affordable Care Act meant that some legislators were afraid to go home on break. Representatives’ offices were picketed, windows  broken, personal safety threatened. Citizens were very unhappy with the ACA’s mandatory coverage and legislated benefits packages that didn’t suit their needs and cost more than their current policies that allowed them to keep their plans and their doctors.

How unhappy were they?

As the October 2013 rollout approached, one health insurance company required training for their call center employees to teach them how to calm down member subscribers. The insurer ordered the training because it knew that it would be sending out letters terminating current policies and replacing them with more expensive, government-mandated ones. They anticipated the tears and anger, and put call center employees through sensitivity training to handle distraught customers.  That company knew well before the ACA launched that people could not keep their plans or their doctors, and that their rates would skyrocket to make up for it. The people who wrote the law, promoted it and voted for it probably knew, too. If they didn’t, they should have been fired.

Oh, wait! They were.

And here we are, in the land of Repeal and Replace.

In an administration where each new regulation requires that two are de-commissioned, we can expect a flurry of confusion from an industry that operates on auto-respond to commands from DC. While healthcare doesn’t like having to zig and zag to expensive orders from DC, providers, insurers, patients, drug and device manufacturers and even IT companies are used to reacting to dicta from federal regulatory agencies.

The most widely, publicly discussed aspects of the ACA pertain to patient coverage. The public is concerned, and understandably so, about the fate of mandatory coverage for pre-existing conditions and the 26-year-old dependent coverage clause. Everyone is required to have coverage so those who flat-out can’t afford it get subsidized. Those who flat-out can’t afford it and don’t meet the income thresholds for a subsidy pay a penalty.  Part of Repeal-and-Replace is figuring out how to address the grievances of those who haven’t fared as well under ObamaCare as they did under their former policies, and assuage those who have benefitted. It’s a job fit for a politician. Other normal humans would not want to find themselves between that particular rock and hard place.

On to the other aspects of Repeal and Replace, those aspects that affect the way the healthcare industry operates and gets paid. What happens to an industry when the regulatory bonds are loosed?

Under the ACA and other related legislation that support various facets the healthcare industry overhaul, doctors face new reimbursement models starting this year based on certain performance targets with rules so arcane that most did not even know late last year that they were subject to the new payment system called MACRA. Other laws resulted in providers and hospitals installing electronic record systems trying to catch the Meaningful Use stagecoach to reach reimbursement targets. Meanwhile, many doctors complained those same mandated electronic records systems were detracting from patient care.

On other fronts, providers are wondering what will happen to accountable care organizations, a concept best achieved with great data capture and analytics that rely on the integrity of the aforementioned electronic health record. Speculation abounds about the fate of other ACA spawn, such as bundled care payments, care coordination and value-based payment models that attempt to support population health in an effort to control costs.  

Finally, when President Trump told a joint session of Congress this week that he wants to loosen the reins on the FDA approval process, you could almost hear a little cheer go up from the pharmaceutical industry. But in the next breath, when he mentioned cutting price deals with drug companies, you got murmuring from the same quarter.

Certainly, many ACA and ACA-spawn initiatives have philosophical merit, as well as their defenders and detractors. The question before the healthcare industry now asks whether an affordable healthcare system can best be reached with less government over-reach?

The answer lies in whether initiatives that are rolled out naturally as a consequence of their merit will lower costs, improve outcomes and increase access, and can do so without adding a regulatory timeline or requiring an outlay of billions of dollars on the part of the government or the health systems that have to dance to the piper’s tune.


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