Next Steps in Health Reform – Immediate

Next Steps in Health Reform – Immediate


The House and Senate need to convene the problem solvers as opposed to the Freedom Caucus bomb throwers and work out the following issues: 1) cost sharing reductions, 2) reinsurance and risk adjustments, 3) care and coverage in rural regions, 4) incentives for cost effective care and 5) the uninsured in the non-expansion states.

The cost sharing reductions reduce copays and deductibles for individuals and families of moderate income. It is a little known but extremely effective part of the Affordable Care Act (ACA), but essential to accessing care in the face of insurance deductibles and copayments that have gotten far too high for middle income families. The Trump Administration and some House and Senate Republicans have been holding its funding hostage on the assumption that this would induce Democrats to jettison the ACA. That has not worked; it’s time to release the hostages so the insurers and Exchanges can negotiate and set their premiums for the coming year. It is time to discuss expanding these cost sharing reductions to more middle class Americans.

Reinsurance and risk adjustment are mechanisms that allow insurers to share the risks of catastrophic care. For less populated states, counties and regions, this is essential to making the health insurance markets work. Why is this so important? Because a small number of cases each year account for a huge percentage of premium costs, and we all hope that we are not in that 1% or so that need care with catastrophic costs far beyond the reach of the average citizen. If the potential risks are too large, the insurers exit these markets. Alaska made it work and the federal government approved a §1332 waiver to allow the state to recapture the savings and fund it for future years. and This was initially a feature of the ACA that was phased down and out, and it needs to be thoughtfully reinstituted.

Rural communities may have only one doctor’s group and one hospital; they don’t need two or three competing plans, what’s the point of that. The ACA model of plan and provider competition simply does not work in communities with natural monopolies. We need instead to build cost effective local collaboration and need to rethink our laws and policies to allow and encourage that to happen. We need to use the available resources on the ground that work. In California, locally operated managed care plans (County Organized Health Systems such as Partnership Health Plan) have been effective in organizing medical care more cost effectively. Clinics and local hospitals in Eureka California are forming partnerships to deliver scarce resources. Nurse practitioners and telemedicine help get care into remote communities. Community clinics are vastly expanding in rural America supported by the ACA. Clinics in Merced, Imperial, Tulare, Kern, Humboldt and Shasta are great examples of this in California. Intermountain in Utah and Geisinger in Pennsylvania show that cost effective local managed care can thrive in rural communities. Medicare is very successful in rural communities as is Medicaid. The issue for much of rural America is too few resources to support a competitive model. So let’s use the models, the infrastructure and the building blocksthat work in rural America, not the models that do not and cannot. Let’s not get and stay stuck in our ideological preferences, but rather let’s get practical and realistic and build on the local systems that already work.

The ACA initiated payment pilots such as bundled payments and accountable care organizations have started to put the health system on the right track to payment reforms. It’s time for Congress to build on those models for the Medicare and Medicaid programs. Transparency of prices, outcomes, quality rankings and effectiveness of treatments are essential to making our American system of care work for every American. The electronic health records and improved use of telemedicine through the ACA and ARRA for better access to specialty care in rural and urban settings hold promise to improve quality and reduce costs and are proving their worth. Let’s identify the problems they face and expand as appropriate.

We must not forget the uninsured in the 19 states that still refuse to expand Medicaid for their uninsured poor; this amounts to new health care apartheid that harms poor black and white citizens equally. If the states won’t act to help their poor, the federal government must now do so. The two logical ways the federal government can act are: 1) open up Medicare or 2) open up the Exchanges to the poor and uninsured. Opening up Medicare has fewer weaknesses in that it's a stable system with solid provider participation; it does have a lot of copays and deductibles, which are a very real barrier to care for the very poor so that would need to be adjusted. Opening up the Exchanges to the poor has appeal to those favoring private sector solutions and those that see great value in private health plans. However some of the state’s individual markets are shaky; private insurers are not covering themselves with glory with their premium hikes and high deductible plans and by picking up and leaving markets annually, and their provider panels have been uncertain in some rural poor communities. While a straightforward Medicaid expansion is the best model for the very poor uninsured and has worked very well in Kentucky, Arkansas and now Louisiana, let’s not let local political antipathies to the program continue to deny coverage in too many other Southern and some Great Plains and Rocky Mountain holdouts.

It is time to press for bi-partisan solutions to real problems not fake solutions to non-existent problems. It is time to repair what needs to be mended and build solutions that can withstand the vagaries of hot political gusts of wind. Candidate Trump waxed eloquent on covering everyone, reducing copays and deductibles and reducing premiums for American workers, let’s hold him to his rhetoric while giving all Americans a win and a model for bi-partisanship.

Prepared by: Lucien Wulsin

Dated: 7/30/17




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