The State of Play Post-Trump/RyanCare

[This column is reprinted from the Commonwealth Magazine website.]

GLOBAL HEALTH EXPERT Michael Reich says that the acid test of any national health reform comes when a new national administration takes over. Only when a new president or prime minister assumes power can we judge the stability and staying power of any health system reform. In the US, that’s this moment. Since November 8, we’ve been learning what parts of the Affordable Care Act (ACA) have staying power, which do not, and what’s uncertain.

Right now, after Friday’s demise of the Republican repeal and replace plan, the American Health Care Act (AHCA), we know that Medicare, Medicaid, insurance market reforms such as guaranteed issue, and delivery system reforms such as accountable care organizations look TrumpCare3

safe. We know that the private insurance coverage reforms – insurance exchanges, premium and cost-sharing subsidies, the individual mandate – are at risk and in danger even though they dodged full repeal with the AHCA’s demise. And we don’t know the fate of the ACA’s many tax increases. Let’s view these systematically. Continue reading “The State of Play Post-Trump/RyanCare”

Exploring the next phase of U.S. health reform

[This article was published on the website of the Harvard Chan School of Public Health in connection with an executive training program — Preparing for What’s Next in U.S. Health Reform — that I’m running May 31-June 2.]

by Lisa D. Ellis

These are uncertain times in American health care. The Republican Congress and President Trump have vowed to repeal and replace the Patient Protection and Affordable Care Act (ACA), commonly called Obamacare. They recently unveiled the American Health Care Act, the replacement plan, which has met with substantial resistance from all parts of the political spectrum. The current political and policy environment has left many health care leaders and other stakeholders wondering what to expect and how best to position their organizations for the next phase of health care reform.

The Potential Effects of Proposed Changes

House Republicans recently introduced legislation intended to create a new health plan, retaining some provisions of Obamacare and eliminating or scaling back others. While the exact details may continue to change in the coming weeks as the bill moves through Congress, there are some specific themes that can be expected in the final version that becomes law, according to John E. McDonough, DrPH, MPA, Program Director of Preparing for What’s Next in U.S. Health Reform and Director of the Center for Executive and Continuing Professional Education at the Harvard T.H. Chan School of Public Health. McDonough, who served as a Senior Advisor on National Health Reform to the U.S. Senate Committee on Health, Education, Labor, and Pensions, explains that there are two major components of the ACA that will be affected by whatever legislation is passed. These are access and value.

Two Main Themes: Access and Value

The first area, access, refers to insurance coverage for uninsured and underinsured Americans. While a significant impact of the ACA was that it expanded its Medicaid offerings to states to cover vulnerable residents, a number of Americans are now at risk of losing this support under whatever new plan is ultimately passed.

There are two major components of the ACA that will be affected by whatever legislation is passed. These are access and value.

“Many, many individuals have gotten health insurance coverage from ACA and [some of them] are quite concerned about whether they will still have coverage in three months, six months, or a year,” McDonough says.

The second area, value, refers to a focus started by the ACA to improve the quality, efficiency, and effectiveness of medical care in the United States. “The evidence shows Americans get care from our medical system that is not as high quality as we have a right to expect because of high costs,” McDonough says. The ACA established a number of initiatives to address this fact, including creating Accountable Care Organizations (ACOs), providing bundled payment plans, and imposing penalties on hospitals with very high rates of readmissions and hospital-acquired infections.

These types of efforts, which are part of a broader push to transform the health care delivery system to ensure a greater focus on value, are receiving widespread support from both Republicans and Democrats, which means that they should continue, and even grow, under any new health care law, McDonough stresses.

“There seems to be a growing sense in the health care community that [the move to value-based payment and population health management] pushed forward under ACA should continue and expand,” McDonough says, adding that this is one piece of good news in the sea of uncertainty that exists.

Preparing for New Developments

Ashish Jha, MD, MPH, Professor of International Health and Health Policy at the Harvard T.H. Chan School of Public Health, Director of the Harvard Global Health Institute, and a practicing general internist at the VA, agrees with this assessment. “The journey we began with ACA to move to value-based health care is going to continue,” he says. “But what form it will take, how we will do it, and how much is voluntary verses mandatory” remain to be seen moving forward.

He points out that this means that professionals need to know the range of options in order to be prepared for whatever way the field goes. “They need to ask, ‘What is the range and how do I prepare, so I will be in good shape?’’’ he explains.

Trends to Watch

Jha, who is also faculty on Preparing for What’s Next in U.S. Health Reform, points to a number of other changes also started under the ACA that, regardless of the final health plan passed, will continue to affect organizations over the next few years. For instance, people today are responsible for a growing portion of their own health care costs. This changes the way that organizations collect their money, meaning organizations need to find new ways of operating.

There will be many moral and ethical dilemmas for organizations as access shrinks and many patients lose coverage under the new plan.

“I think health care leaders are very used to a world where they provide services to patients and get paid by insurers, or the government/Medicare or Medicaid. But now they’re waking up to a new model where they are getting a larger chunk from patients. They’re not used to collecting money from patients themselves and that will change their relationships,” Jha says.

With customers footing more of the bill, they now have higher expectations from providers. “The customer is changing, and what will customers want in return now that they’re writing the check? That becomes a really important issue for providers to focus on. It’s part of patient-centered care. Now patients are in the driver’s seat,” he stresses.

Another issue worth paying attention to on the value side of the equation is that participation in some Medicare bundled payment programs will be voluntary for now, but is ultimately expected to become mandatory in the not-too-distant future. This raises some interesting questions for organizations, as they grapple with whether to use the voluntary program to get acclimated. Organizations that don’t participate now could end up having a lot of catching up to do in the future, which could “have very serious consequences three to five years down the road,” Jha says.

Issues to Watch

On the access side of things, Jha points out that there will also be many moral and ethical dilemmas for organizations as access shrinks and many patients lose coverage under the new plan. Five years ago, many people were uninsured and had no contact with the health care system. “Now, these people have been covered and have become part of the organizations [that serve them]. They have developed relationships with their doctors, so it’s a big difference now when they lose coverage,” he says. “Are organizations really going to walk away from these patients? [And if not], how will health systems manage the financial debt they will incur to care for the uninsured?”

Another important trend that will impact many health organizations moving forward revolves around consolidation. “Doctors are being bought out by big hospitals. We have no idea how the Trump Administration will feel about that. Consolidation is a strategy that provider organizations have used to survive, getting bigger. But that gravy train for providers is coming to an end. Now, with more people uninsured, and more focus on value, there are broader market issues around consolidation and integration that will be challenging for providers,” Jha says.

Other Trends Worth Following

Other trends that will continue to impact organizations include the growing push for providers to use interconnected Electronic Health Records (EHR). This is an important tool to help track and achieve key benchmarks of value-based care and improve coordination among providers for increased efficiency and better outcomes. “While everyone thinks this is a good thing, and most organizations have made the leap into EHRs, people, especially frontline doctors and nurses, are very frustrated with these systems.  How organizations will manage the transition between simply adopting the EHR and using it in ways that lead to meaningfully better care is the challenge ahead,” Jha says.

In addition, Jha says that the Trump Administration’s tougher restrictions on immigration may have a real effect on health systems that needs to be addressed up front. “Twenty-five percent of doctors in our country are foreign medical graduates, as are a large population of our nurses and other health professionals,” he says. “As immigration gets tighter, there’s a question as to whether we will have a harder time attracting the best and brightest in the world. So health care will have a hard time building their ranks” in the future. With an aging population, this means that health systems may have challenges creating a good workforce to care for them.

The Importance of Staying Up-to-Date

With so many fluctuations expected in how the health care system will do business in the coming months and years, both Jha and McDonough say that it is crucial for health care leaders to stay abreast of the latest developments as they progress.

One of the most important things is for health care leaders to stay in touch with what is happening out there and pay attention to the coverage in the media.

“One of the most important things is for health care leaders to stay in touch with what is happening out there and pay attention to the coverage in the media,” McDonough says. “If you work in a hospital, [you will need to] follow the national organizations, such as the American Hospital Association, and stay alert to the opinions of experts as to what might happen,” he says. But that alone will not be enough, says Jha. Understanding the nuances of policy changes will be critical for leaders to stay on top of the shifting requirements—and opportunities—that exist in the current environment so they can strategically position their organizations for success.


Harvard T.H. Chan School of Public Health offers Preparing for What’s Next in U.S. Health Reform, which offers key lessons involving health reform from the nation’s leading policy experts under the new federal administration. To learn more about this opportunity, click here.

24 Million May Lose Health Insurance to Pay for Tax Cuts for Wealthy Americans

[This commentary, “GOP Cuts Are Moral Challenge for America,” was published on Commonwealth Magazine’s website on March 14.]

THE BIG NEWS IS, of course, Monday’s “score” from the Congressional Budget Office detailing that the House Republican bill to repeal and replace the Affordable Care Act/Obamacare will result in 14 million Americans losing health insurance by 2018 and 24 million by 2026.

Before that, something else caught my eye from the Bangor Daily News. It’s a blog post from a woman named Crystal Sands who writes about how the ACA enabled her and her young family to take a chance and find a new life as farmers. Her post, “The ACA makes a simpler farming life possible for our family,” says this:

“I’m a writer, an online professor, a farmer, a wife, and a mom. None of these jobs offer health insurance for me and my family, so our family purchases our health insurance through the Affordable Care Act. We work hard, but we try to work differently. If you read my blog, you know we’re learning to grow and raise our own food, and our health insurance through the ACA makes this possible.

“The ACA has helped me to become a better mom, a better wife, a better teacher because I am not so overworked, and it has made it so I can learn to be a farmer. I’m also just a better person. I’m not sick and overworked. I’m more patient and more kind and more helpful to everyone. And this is my story. There’s so much potential here to make lives better. There are many people, including many farmers, who depend on the ACA. I hope we don’t lose sight of that.

And now, CBO’s Cost Estimate of the American Health Care Act. Bottom line — $894 billion in tax cuts financed by $1.2 trillion in cuts to Medicaid and to subsidies/tax credits for private health insurance. Those cuts will produce an increase in numbers of uninsured Americans of 14 million by 2018, 21 million by 2020, and 24 million by 2026. Of the 24 million, 14 million will lose Medicaid and 10 million will lose private coverage, employer-sponsored and individual. Continue reading “24 Million May Lose Health Insurance to Pay for Tax Cuts for Wealthy Americans”