Reframing Prevention in the ACA Era

This article, “Reframing Prevention in the Era of Health Reform,” was co-authored by Dr. Howard Koh, Dr. Rahul Rajkumar, and me in the September 13 2016 issue of the Journal of the American Medical Association:

The 2010 passage of the Affordable Care Act (ACA) raised numerous opportunities for disease prevention. Of the 10 legislative titles comprising the ACA legal framework, Title 4 (“Prevention of Chronic Disease and Improving Public Health”) initially held the most promise for delivering new financial resources as well as effective policy for prevention.1 Six years later, Title 4 outcomes show mixed results. In the meantime, however, other ACA innovations are redesigning health systems by incorporating prevention into a range of new care models. Doing so connects the clinic and the community in ways not necessarily envisioned in the statute, thereby broadening possibilities for the future of population health.

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How Might Democrats Try to Expand and Improve the ACA in 2017?

[Below is a new commentary just released by the Milbank Quarterly on their website — to be published in their fall edition.]

In 2017, if Democrats hold the White House and recapture a majority in the US Senate (control of the US House is considered unachievable), how might they try to change the Affordable Care Act (ACA)?

Despite congressional gridlock, changes to the ACA have happened. Six years since its enactment, the ACA has been altered 24 times by Congress and the president, mostly in response to Republican demands that generated some support from Democratic lawmakers as in the 2013 wholesale repeal of the ACA’s Title VIII, a new disability cash assistance program known as Community Living Assistance Services and Supports (CLASS—RIP).1

While Democrats and progressive groups have wish lists for ACA improvements, they have kept these low-key, prioritizing instead the need to repel repeated existential threats to the law, such as the 2 anti-ACA lawsuits that reached the US Supreme Court in 2012 and 2015 (National Federation of Independent Business v Sebelius and King v Burwell, respectively). Continue reading

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The Art of the Non-Deal Deal

[This article on the demise of the proposed ballot initiative to address hospital price variation was just published in the new summer issue of Commonwealth Magazine.  I first wrote about this issue in an article the winter issue of Commonwealth Magazine in January 2016.]

On May 31, Gov. Charlie Baker signed a new law to avert a proposed 2016 state ballot initiative that would have redistributed as much as $450 million annually from Partners HealthCare hospitals to most of the state’s other hospitals by establishing stringent limits on hospital price variation.  The new law, “chapter 115 — an act relative to equitable health care pricing,” is less than a shadow of the ballot petition advanced by the state’s health care workers union known as Local 1199 of the Service Employees International Union (SEIU).  Is the new law progress? Is it enough?

The clear winners are SEIU and Partners because both got what they most wanted, as well as Baker, Senate President Stan Rosenberg, and House Speaker Robert DeLeo who deflected the ballot question.  If anyone else wins, that is a matter of dispute. Less disputable are lessons about the state of Massachusetts health care politics and policy in the Baker era. Continue reading

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Obama, Clinton and the New Public Option

The era of Democratic silence on strengthening and improving the Affordable Care Act is officially over.  President Barack Obama’s tour de force review of the ACA’s successes in the new Journal of the American Medical Association is also important for his identification of key ACA improvements needed on insurance affordability, Medicaid, prescription drug prices and more. I note his call for a “public option” health plan to spur competition in states with low numbers of health insurers participating in state ACA exchanges/marketplaces:

“…(I)n the original debate over health reform, Congress considered and I supported including a Medicare-like public plan. … Now, based on experience with the ACA, I think Congress should revisit a public plan to compete alongside private insurers in areas of the country where competition is limited. Adding a public plan in such areas would strengthen the Marketplace approach, giving consumers more affordable options while also creating savings for the federal government.”

Serendipitously, Sect. Hillary Clinton is now actively promoting the public option in her White House run, partially to woo backers of her Democratic opponent, Sen. Bernie Sanders (D-VT), and also because she has supported this idea since 2008:

“To make immediate progress toward that goal, Hillary will work with interested governors, using current flexibility under the Affordable Care Act, to empower states to establish a public option choice.”

What does the “public option” mean and why now? Continue reading

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House GOP ACA Replacement Plan Is an Empty Backpack

This week, US House Speaker Paul Ryan released a long-promised plan to replace the Affordable Care Act. Most of the plan, “A Better Way: Health Care,” developed by a House task force, includes familiar ideas that have been in Republican rhetoric even prior to the ACA. Coverage of the plan’s basics can be found here and here and here. Is there anything new, important, or revealing in this? Yes. Here is my list:

First, Team Ryan does not want you to know the cost or coverage impact of their proposal. Team Ryan is plenty capable of producing a legislative draft that could be scored by the backpack2Congressional Budget Office, and chose not to do so because that would be telling. Indeed. The ACA repeal legislation they sent to President Obama’s desk (subsequently vetoed) this past January would have eliminated health insurance for 22 million Americans who got it via the ACA. Is this new plan better? Team Ryan doesn’t want you to know.

Second, Team Ryan wants to eliminate income-based subsidies in favor of a flat tax credit. The most important reason people lack health insurance is because they don’t have enough income to afford it. The ACA’s structure is based on income – the most assistance goes to those with the least means, ending at 4 times the federal poverty level, or $97,200 for a household of four. Team Ryan offers a flat tax credit for anyone who can’t get employer coverage that would leave most people under 300% unable to afford coverage. How many? It’s impossible to say because Team Ryan doesn’t indicate the size of the credit. Continue reading

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Back to the Future with Speaker Paul Ryan

This past week at Georgetown University, House Speaker Paul Ryan proposed scrapping an essential component of the Affordable Care Act (ACA) that bans health insurance companies from imposing pre-existing condition exclusions on consumers and prohibits the practice of “medical underwriting” to discriminate against anyone with a current or prior medical condition. Instead, he proposed, states could re-establish “high risk pools” from which those with pre-existing conditions could obtain coverage, leaving standard health insurance only for the “healthy.”

Paul Ryan 2Christopher Lloyd

Wow. Ryan may or may not realize it – but his speech just changed the stakes regarding the ACA and the November 8 federal elections.

Prior to Ryan’s speech, conventional wisdom, as evidenced in Republican Congressional and conservative think tank proposals, was to preserve the ACA’s ban on pre-existing conditions, albeit only for those who maintain “continuous coverage.” This stance enabled Republican office-holders to affirm their support for the pre-ex ban, even as their proposals’ fine print would reintroduce medical underwriting. Continue reading

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Behind the Bipartisan Kumbaya on Substance Abuse

[This op-ed was posted yesterday on the website of the Milbank Quarterly.] 

For several years, Republicans and Democrats alike have been concerned about the crisis of opioid and heroin addiction in the United States. It is hard to find anyone who rejects the notion of a serious problem that demands at least a partial governmental response. Across the nation, governors and legislatures are hard at work seeking solutions and avoiding partisan bickering. Numerous current and former presidential candidates in the 2016 campaign cycle got favorable attention explaining how the crisis has affected their families and friends in personal ways.

Behavioral health

The question is whether there is any meaningful difference between Republicans and Democrats when it comes to substance abuse (and, for that matter, behavioral health—the merger of substance abuse and mental health).

The answer is yes, and the difference comes down to the Affordable Care Act (ACA). Continue reading

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Behind the Turnaround at the MA Health Connector

(This article was just published in the Spring Issue of Commonwealth magazine.)

It’s 11:59 PM on October 31, 2015, about 20 nervous state officials and contractors hunched around computer terminals in a non-descript office in the Charles F. Hurley Building near Beacon Hill. Among them was Louis Gutierrez, executive director of the Massachusetts Health Connector, appointed the previous February by newly inaugurated Gov. Charlie Baker. The launch of the third open enrollment since the 2013 implementation of the federal Affordable Care Act (ACA) was less than a minute away with lots on the line. Would months of hard preparation avoid another website calamity that could jeopardize health insurance for hundreds of thousands of Massachusetts residents.

As the website opened at midnight and kept humming without a hitch throughout the night and following days, sighs of relief were heard across the Commonwealth as a major governmental embarrassment was averted. By early February 2016, 201,000 state

Guttierez

Louis Gutierrez

residents had successfully enrolled in plans for 2016, including 36,000 new members. Today, the Connector is a marquee success for the still-youngish Baker administration — an ironic twist for a Republican governor who was never a fan of the ACA, Barack Obama’s marquee presidential achievement. Continue reading

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Massachusetts Health Reform at 10 – A Surprising Look Back

April 12th is the 10th anniversary of the signing of Chapter 58, Massachusetts’ landmark universal health insurance law (An Act Providing Access to Affordable, Quality, Accountable Health Care) that served as a key model for the federal Affordable Care Act (ACA/ObamaCare) signed in March 2010. A more compelling example of states as “laboratories of democracy” is hard to find.

A lot of good material has come out in the past 24 hours: a literature review of evidence on the law’s impact from the Blue Cross Blue Shield Foundation of Massachusetts; 13 essays on the law by various Massachusetts health policy players (including yours truly) with an overview by WBUR’s Martha Bebinger; and a helpful retrospective from Health Care for All’s Brian Rosman.

Looking back over newsclips and materials from April 2006, I found an arresting editorial supporting Chapter 58 written by Ed Haislmaier, a Senior Research Fellow at the Heritage Foundation. His article was called “The Significance of Massachusetts Health Reform.” Here are some direct quotes:

“Some commentators, by getting wrong even the most basic facts of what the legislation actually does, have offered wildly inaccurate interpretations of the bill and its likely effects.”

“The basic insight behind a state-sponsored health-insurance clearinghouse or exchange (like the Connector) is that markets sometimes work more efficiently and effectively when there is a single place to facilitate diverse economic activity. Like a stock exchange, the health insurance Connector in the Massachusetts legislation will be a clearinghouse to match buyers and sellers efficiently and to facilitate the collection and transmission of payments, often from multiple sources.”

“The Governor and legislature have provided their citizens with the tools to achieve what the public really wants: a health system with all the familiar comforts of existing employer group coverage but with the added benefits of portability, choice, and control.”

“Other governors and legislators would be well advised to consider this basic model as a framework for health care reform in their own states.”

From today’s vantage point, it’s hard to believe this came from the Heritage Foundation, but then, maybe not so much. Heritage was founded in 1973 as a conservative alternative to the Brookings Institute and placed itself in the ideas vanguard of the 1980s Reagan revolution. Unlike other policy shops back then, Heritage proactively sought to connect conservative and libertarian thinkers with friendly members of Congress and Administrations. They nurtured ideas and sought champions for them.

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Trump’s Health Plan = 21 Million Uninsured, $270-500 Billion Budget Hole

On March 14, the Committee for a Responsible Federal Budget (CRFB), a bipartisan federal budget watchdog group, released an economic analysis of the recent health proposals made by Republican Presidential candidate Donald Trump.  Their key findings:

“Donald Trump’s plan to repeal and replace Obamacare would cost nearly $500 billion over a decade, or $270 billion incorporating economic growth.

“The plan would nearly double the number of uninsured, causing almost 21 million people to lose coverage.”

To my knowledge, this is the first serious and independent economic analysis of any Republican or conservative health reform plan released since the Affordable Care Act (ACA) was signed in 2010.  It’s not a pretty picture.

UninsuredDoubleUnderTrump

In addition to “completely repeal(ing) Obamacare,” Trump’s proposal would:

  • Allow sale of health insurance across state lines;
  • Allow individuals to fully deduct health insurance premiums from their income tax obligations;
  • Allow individuals to use Health Savings Accounts;
  • Require transparency from all health care providers;
  • Block grant Medicaid to the states;
  • Remove barriers to entry into free markets for drug providers.

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