Senate Republicans were unable to get the 50 affirmative votes needed to pass the “skinny” repeal of the Affordable Care Act (ACA) on July 28, 2017 in the pre-morning hours. It was a scary night in the Senate chambers, but sanity prevailed. All Democrats and three Republicans voted against the bill—ending this particular round of legislative ACA-repeal attempts.
Although all of us who were frightened of the recent Republican-crafted bills can now exhale in relief, the “cease-fire” may be all too brief. This is because President Trump and Republican Party members of Congress are determined to repeal the ACA. After all, they promised—as candidates—that this would be accomplished if elected by their voting supporters.
Budgeting as a Mechanism for Health System Weakening
We do get a fortunate respite from legislative attacks on our health system. That’s the good news. However, the next ACA attack may come from the Department of Health and Human Services (DHHS) budget under Health Secretary Tom Price’s leadership (and as a Trump Cabinet appointee).
As a former member of the House of Representatives for 12 years (Republican-Georgia), he was Chairman of the House of Representatives’ Budget Committee. During his tenure, he was an ardent and vocal foe of the ACA. His perspective is that there should be no federal oversight of healthcare.
Meanwhile, Seema Verma at the Center for Medicare and Medicaid Service (CMS) is also fervently against the ACA. Scott Gottlieb—Head of the Food and Drug Administration—is yet another Trump cabinet member who is an opponent of the ACA and federal regulatory authority.
In tandem with Trump’s other Cabinet members, these appointees can do a huge amount of damage to ACA functional ability through funding decisions. By encouraging ACA failure through their decisions (rather than strengthening the ACA) the Trump Administration and conservative Republicans can then claim they were correct; the ACA was indeed on the brink of collapse.
Unfortunately, we may all—in the coming years—be “collateral damage” in this fight between mainly-partisan ACA opponents and supporters.
How Destabilizing the Insurance Industry Weakens the ACA
While I am not an enthusiast of the federal government funding insurance companies (or other private firms), the Congressional Budget Office (CBO) report of July 27, 2017 found that repealing the ACA-requirement for all persons (both healthy and sick) to have health insurance would lead to an insurer response of higher premiums.
Insurance industry studies have repeatedly shown that the absence of healthy persons from the insured “pool” results in higher insurer costs. (After all, sick and disabled individuals utilize health services at a far higher rate than healthy people.) Since insurance companies plan their budgets at least a year in advance, uncertainty causes a defensive reaction to protect their revenues.
In terms of the ACA’s federal exchanges, this can mean insurer pull-out, higher enrollee premiums to offset costs, or higher deductibles. Consequently, more people might choose to pay the ACA’s financial penalty for not buying insurance than incurring the expense of a health plan with an unaffordably-high premium or deductible.
What “Fixing” the ACA May Entail – Innovating and More Regulating
I am a proponent of the “single-payer” health system, albeit with some reservations. There are certainly many people who have experienced obstacles in receiving timely medical services under this type of system. However—in England and Canada—the majority of residents are satisfied; national surveys have shown that the populations of these countries would not willingly choose to return to their prior (non-“single-payer”) systems.
In contrast, a longstanding conservative campaign to associate a “single-payer” health system with socialism (as linked to the political and economic system in the Soviet Union) has made its adoption unlikely in the United States. Strategically, socialized medicine is widely promoted—and perceived—as evil.
Yet, more government oversight (not less) may actually be the treatment needed to “fix” the ACA. In other words, pharmaceutical costs, medical school costs, insurer net income, and hospital charges may all need to be curtailed, for the ACA to lower the national healthcare cost-burden as intended.
Patient-Centered Medical Homes and Preventive Care
Patient-Centered Medical Homes (PCMHs) are a model that CMS-funded projects (under the ACA) have embraced in order to control healthcare costs. Through targeting duplicated services for elimination, a major aim of these projects has been payment reform. Curtailing the national healthcare expenditure through the ACA’s promotion of preventive care cannot fully be evaluated until years into the future—but the public-at-large and elected representatives generally want to experience immediate results in order to support a government-funded program.
Stakeholder and Financial-Donor Influence
The key stakeholders in the U.S. healthcare delivery system may advocate against more government intervention, in tandem with conservative individuals who are large-scale donors. Meanwhile, super PACs are financially supporting their efforts to severely-limit government involvement in the healthcare system.
On the other hand, the “good old days” of unregulated and free-market healthcare got us into this mess. Thus, it can’t get us out of it.