​​​​​​​The Winners and Losers in the Senate Healthcare Bill and the Four Themes Not Addressed at All

Thursday, Republicans in the U.S. Senate released their bill, the Better Care Reconciliation Act (BCRA), which now awaits scoring by the Congressional Budget Office and a vote in their chamber. If 50 Senators plus VP Pence approve, it will then be referred to a Joint Conference Committee where differences between it and House-passed American Health Care Act (AHCA) will be ironed out, a bill produced that would then become law after signing by President Trump presumably before the August recess. That assumes deals will be cut with the 5 moderate Senators who think BCRA budget cuts harmful and 4 who think the cuts don’t go far enough in curtailing federal spending for Medicaid.

There are notable similarities in the two GOP bills: both cut funding to Medicaid over several years, repeal the individual and employer mandates to purchase coverage, eliminate $1 trillion in taxes for insurers, medical device manufacturers and high income individuals, loosen restrictions and grant insurers more flexibility in designing and pricing their plans and shift huge responsibilities to states to oversee Medicaid via block grants, individual insurance marketplaces and insurer compliance with lessened federal oversight.

The major differences between the two are (1) the Senate bill funds the much-discussed cost sharing subsidies to insurers missing in the House bill and (2) delays major changes to Medicaid until after 2021 but cuts federal funding more long term via its formula tied to the overall consumer price index vs. the medical inflation rate that’s higher.

It’s anyone’s guess about the prospects for a Senate vote this week but it seems likely the Republicans will get a law passed that Repeals, in part, elements of the Affordable Care Act. That assumes arm twisting and deals with 7 of the 9 hold-outs based on amendments to the law and deal-making. That’s how the sausage is made in DC. Recall that in March, 2010, the same was necessary to get 13 hesitant Democrats in the House to approve the ACA.

And lest it be forgotten, other parts of the ACA—the transition from fee for service to value-based purchasing, transformation of the healthcare workforce, development of the comparative effectiveness research platform, transformation of the U.S. healthcare workforce, development of a national quality of care strategy and other elements—will likely be addressed through administrative action or willful inaction by the Secretary of Health and Human Services and through budgetary maneuvers whereby funds will be redirected from programs the GOP dislikes like the Center for Medicare and Medicaid Innovation and others. Thus, the GOP expects to lay claim to its pledge to Repeal and Replace the Patient Protection and Affordable Act going into the 2018 and 2020 campaign cycles and pivot to immigration, tax reform and other issues where it believes it faces less political risk.

I read the BCRA three times Friday. It’s basically a 142-page edited version of the American Health Care Act with some unique twists that actually make it more hawkish toward healthcare spending by the federal government. But, in essence, the two bills are close. So, if you’re keeping score, here’s the scorecard for winners and losers based on a fairly safe assumption that something akin to the two will pass:

Winners:

    GOP Congressional Incumbents in safe districts or Red states who bet the ranch on Repeal and Replace. They’ll claim they kept their promise (though major elements of the Affordable Care Act are still the law of the land).

• Insurers who got relief from regulations about essential health benefits, flexibility in pricing premiums of their plans, and cost sharing subsidies through 2020 from the federal government to keep enrollment steady in their individual products. Currently, 7 million Americans would benefit from the cost sharing subsidies included in the Senate bill, but they expire in two years.
• Employers who are now free to offer employee coverage that shifts financial risk to their employees via Health Savings Accounts coupled with high deductible coverage.
• Medical device manufacturers who get relief from their excise tax and wealthy individuals who get tax breaks.
• Young adults without pre-existing conditions who’ll see their premiums go down if they choose to purchase coverage.
• Proponents of a single payer solution who’ll see the GOP led effort as a catalyst for their cause.

Losers:

• Hospitals and physicians who’ll see their margins shrink and uncompensated care increase as the ranks of the uninsured increase, those with commercial coverage have higher out of pocket responsibilities, and cuts to Medicaid are implemented.
• Nursing home, home care and post-acute providers, who are recipients of 42% of Medicaid funds.
• Low-middle income adults who are just above Medicaid eligibility who will see premiums rise and subsidies disappear.
• States who will bear greater burden in funding and managing the Medicaid and individual insurance markets.
• Individuals with pre-existing conditions, the disabled and seniors who will find coverage unavailable or unaffordable.
• And the 3 million opioid-addicted individuals who are treated through Medicaid: they’re dying at a rate of 91 per day.

In 2009-10, I facilitated a number of meetings involving industry leaders and the White House Office of Health Reform. The circumstances were similar: health reform was the high-profile issue with huge political risks on all sides. The President promised to increase access to coverage and reduce costs. Congress and the White House were controlled by one party. The public was divided: half felt coverage was a universal right; the other half saw reform as a government funded entitlement that could de-stabilize our economy and drive deficit spending up.

In the Affordable Care Act, change focused on expanding insurance coverage first vis a vis Medicaid expansion and subsidies for low income individuals and small businesses.  Long-term cost reduction was a secondary issue. There were notable flaws in the ACA, just as there will be flaws in its replacement now being crafted by the GOP. This time, it’s about reducing costs first by curtailing federal spending for Medicaid and subsidized coverage with downstream implications for expanded coverage secondary.

I am thankful health reform is on the public’s mind again. But the current debate has been incomplete and sometimes prone to “fake news”. Four themes have been missed in the rhetoric on both sides:

Access to insurance coverage is not the same as access to care. For those wishing to focus on coverage as the only basis for reform, the data is clear: having insurance coverage is associated with a healthier life and better care, provided the coverage actually covers needed care.

There’s plenty of money in the system, but much is wasted and it’s not spent in the most productive ways. We spend $10,000 per person on healthcare in this country, but a fourth of the population does not have access to preventive health and our primary care safety-net is riddled with holes. Reducing unnecessary care, eliminating redundant administrative burdens and smart purchasing of drugs and technologies would save $800 billion per year—more than enough to re-engineer the system toward better outcomes, expanded coverage and near universal access.

The Medicaid program needs transformation: budget cuts without program re-design does nothing to fix it long-term. Medicaid covers 74 million Americans at an annual cost of $389 billion this year. It’s increased 9% from last year, is forecast to increase at 6% annually going forward reaching $650 billion in 2027. The unintended consequence of cutting Medicaid reimbursement and dumping it on the states means more uncompensated care for providers, who will, in turn shut their doors or raise their prices. Transformation of Medicaid is fundamentally about managing population health that merges health and human services programs. Its foundation is primary and preventive health that covers physical and mental health, nutrition, health coaching and more. It’s innovation in technology-enabled care and post- acute care coordination for the most fragile. Giving states fewer dollars and more leeway in managing the program is a recipe for failure.

Affordability has not been addressed. In the 2009-10 version, affordability was defined in the context of a ceiling—9.5% of adjusted gross income—beyond which low income individuals could receive subsidized insurance coverage. In the current version, affordability is defined in the context of lower premiums set by insurers, with adjustments made to keep them lower for the youngest and healthiest. But missing is an approach to reducing the underlying cost of affordable care which encompasses much more than insurance premiums: we pay the highest prices in the world for drugs, technologies and hospitalization. The rest of the world pays less for the same. And our system incentivizes using more of these, not less, because we haven’t used our buying power to lower what we pay. The result is care that’s affordable to fewer and fewer.

Maybe, after the dust settles from the Senate-House Joint Conference deliberation, the opportunity to address these issues will get attention.

Maybe, after the 2018 and 2020 election, healthcare policy and the future of our health system will be revisited sans the political bickering and grandstanding recently seen.

Maybe, health reform, after all, is not a Blue or Red issue at all: it’s bigger and more important than that!

Paul

P.S. This week, we’ll see the Congressional Budget Office score for the Better Care Reconciliation Act and the Senate GOP’s deal-making to get it passed with 50 votes plus VP Pence. It will come down to the wire. Stay tuned.