A Republican Path to ACA Reform

[This commentary, written by me and Dr. William Seligman of the Harvard Chan School, was published today on the Commonwealth Magazine website.]

IF PRESIDENT DONALD TRUMP and Congressional Republicans were to decide that fixing rather than destroying the Affordable Care Act, especially its private health insurance marketplaces, was in their self-interest, could they do it?  And, could they do it in a way that aligns with Republican policy preferences?

The answer to both questions is “yes” – if Republicans heed lessons from their two favorite public health insurance programs. The programs are Medicare Part C, called Medicare Advantage, in which enrollees join private health insurance plans, and Medicare Part D, in which enrollees join private outpatient prescription drug plans.

While Republicans defend and brag about both of these reasonably successful programs, they may be surprised to learn that features of both point the way to successful stabilization and growth of the ACA’s private health insurance marketplaces.  Here’s how.

Medicare Advantage: From Bust to Boom

Consider these two quotes:

“People’s premiums are going up 35, 45, 55 percent … The market is disastrous, insurers are leaving day by day, it’s going to absolutely implode.”

“They’re anguished, upset, frustrated and angry by the demise of their plans. … They’re facing increasing premiums and…plans are leaving the market.”

The first quote is President Trump talking recently about the instability of the ACA’s marketplaces.  While most non-partisan observers disagree with the severity of his characterization, most – not all – of the federal, and some state, marketplaces are experiencing undeniable distress.

The second quote is from former congresswoman Nancy Johnson, a Connecticut Republican, talking in 2001 about the “Medicare + Choice” marketplace in which Medicare enrollees join a private health plan instead of participating in traditional fee-for-service Medicare (Parts A & B). Continue reading “A Republican Path to ACA Reform”

MassHealth Dives into Accountable Care

[I wrote this commentary for the Spring Issue of Commonwealth Magazine to profile Massachusetts’ new move into accountable care organizations, an experiment that deserves watching.  Dr. William Seligman co-wrote with me.]

IN A WILDLY uncertain national health care environment, something new, audacious, and risky is happening in MassHealth, the Medicaid program that provides health coverage to 1.9 million people who are poor, elderly, and persons with disabilities in Massachusetts. Gov. Charlie Baker’s administration is betting that an emerging health care delivery and payment model, called “accountable care organizations,” can restrain rising costs by keeping enrollees healthy and out of expensive settings, especially hospitals. Positive results will have big consequences for the state, for medical providers, and for hundreds of thousands of MassHealth enrollees who will become part of ACOs this year and into the future.

The ACO scheme is the major part of a massive new federal Medicaid waiver that Team Baker won from the outgoing Obama administration days before the November 8

MassHealth spending 17

election that put Donald Trump in the White House. The Obama administration liked the Baker plan because it fit with their mission to move US health care away from expensive fee-for-service payment and toward value-based financing that rewards quality and efficiency. Though no one knows for sure which way the Trump administration will move, right now it’s full speed ahead at MassHealth on the ACO agenda. Continue reading “MassHealth Dives into Accountable Care”

Health and Taxes and the Values at Stake in the ACA Debate

[This commentary was published this week on the website of the Milbank Quarterly.]

One of my favorite political scientists, Deborah Stone, wrote that much of the policy process involves debates about values masquerading as debates about numbers and facts.1 Although her construct is abundantly in evidence, it is being overlooked in the current debate over the future of the Affordable Care Act.

How much are premiums rising? How many plans are operating in the exchanges? How much money are accountable care organizations saving? What impact would a per capita cap financing scheme have on Medicaid? How much has the ACA restrained or propelled health cost growth? What do opinion polls show?

Each side furiously hurls data and anecdotes at each other as if by identifying the killer data point, the other side would throw up its hands in surrender and declare: “How could we have been so dumb?” Of course, this never happens in public policy debates. It never happens because numbers and anecdotes don’t motivate people on an issue as charged as the ACA. Values do. Continue reading “Health and Taxes and the Values at Stake in the ACA Debate”