Mad About States

[This column was just published on the website of the Milbank Quarterly.]

A consistent theme in 2017 Republican Congressional efforts to repeal and replace the Affordable Care Act (ACA) was the intent to empower the 50 states to use federal funds to reengineer their Medicaid and individual health insurance markets as they see fit. If yet another Republican attempt at ACA repeal and replace happens in 2018, the most likely vehicle will be a reformulated Graham-Cassidy bill, the final 2017 repeal effort in the US Senate that featured far-reaching devolution to states. The idealization of states as the best makers of health policy is a myth worth busting.

States, goes the thinking, are closer to the people than those who govern from Washington, DC, more attuned to real-world preferences and values than feds. States are nimbler, better at adjusting and innovating than the plodding feds. States are, in the high-minded and oft-repeated words of late Supreme Court Justice Louis Brandeis, “the laboratories of democracy.”

As Republican Senator Bill Cassidy (R-LA) wrote in the Washington Post this past July, “Returning the decision-making power to the states is not a Republican plan or a Democratic plan, but an American plan that reflects the faith in states held by our Founding Fathers.”1

As someone who has labored for decades in the vineyards of state health policy, I reply, nonsense. I give states their due. Massachusetts, for example, provided the inspiration for both the 1997 Children’s Health Insurance Program (CHIP) and the 2010 private health insurance reforms in title 1 of the ACA. Democratic and Republican leaders there and in many other states have forged successful bipartisan approaches to some of America’s thorniest health challenges. Yet the notion that states have innate wisdom and a tighter finger on the pulse of the people always superior to the federal government is not true. One example will do. Continue reading “Mad About States”

Pray for the Dead and Fight like Hell for the Living.

[The Washington Post’s Health 202 Column offered a set of “eulogies” on the fate of the ACA’s individual mandate — the mandate penalty was reduced to zero by the Republican’s newly approved tax-cut legislation.  I had the last word…] 

… So it’s not shocking that’s the part of Obamacare they chose to target in their tax overhaul, especially since their chance at a health-care bill seems to have passed. Democrats and advocates for the ACA have known for a while this was likely coming down the pipeline – and there was not much they could do to stop it.

Yet Republicans have talked for so long about repealing the mandate, election cycle after election cycle, it’s still hard to believe we’re actually standing here.

The Health 202 asked leading health-care wonks — on the right as well as the left – to offer some parting comments. Let’s call a eulogy of sorts.

–Andy Slavitt, former Centers for Medicare and Medicaid Services administrator under Obama: “The main effect of Republicans’ action today is to raise the cost of insurance for middle class families. The law has proven to be highly resilient and actions against it look increasingly petty. As a larger matter, to Republicans’ chagrin, they have now removed the only unpopular feature of the ACA. The rest of it enjoys overwhelming popular bipartisan support and will be much harder to remove.”

–Chris Jennings, former health-policy advisor to Obama: “Not overly original, but true: You break it, you own it and all the associated increases in premiums, out-of-pocket costs and uninsured Americans. Congratulations.”

–Jim Capretta, former Office of Management and Budget health-care director under George W. Bush: “There’s some exaggeration on both sides of the debate about the individual mandate. Advocates of the mandate say that its repeal will devastate the individual market. There’s not much evidence for this view. On the other hand, opponents of the mandate sometimes say its repeal will have no effect at all.  That’s also not true.

“The individual market under the ACA is already somewhat unstable, and is suffering from an elevated level of adverse selection. The repeal of the mandate is going to make this not-so-great situation slightly worse. But the market is unlikely to collapse, as the ACA subsidies are sufficient to induce significant enrollment even without the mandate.  Republicans now have some responsibility for the functioning of the marketplaces. Unfortunately, it does not seem like GOP leaders in Congress or the Trump administration have a clear idea of what they would like to do once the mandate is repealed.”

–Tom Scully, CMS administrator under George W. Bush: “I don t think the mandate ‘repeal’ will make a big difference. A Trump IRS was not going to enforce the penalties anyway. I am sure that insurers would prefer that it stay in place, but I bet he real behavioral impact will be minimal.”

–Newt Gingrich, former GOP House speaker (who once supported the idea of an insurance mandate): “A bad idea passed in a bad way and repealed in a classic American model of clumsy but correct.”

–John McDonough, Harvard health-policy professor: “As Mark Twain is reported to have said on May 31, 1897, ‘the report of my death was an exaggeration.’ The legislation reduces the penalty for non-compliance with the mandate to zero. The legal requirement remains intact.

“This is not trivial. It will not take long for the damage from the zeroing out of the ACA penalty to become clear. Because Massachusetts still has an enforceable mandate — and penalty — on its books, we will have speedy evidence of the impact of this policy change.

“In 2019 or 2021, a future Congress that cares about the stability and workability of the nation’s individual health insurance market, unlike the current Congress, will revisit this policy and likely re-establish a workable new policy.”

The Republican Tax Cut’s Silver Linings Playbook

[I’ve been super busy this fall and unable to keep up with writing about the ACA.  I’m back in the saddle and here I go again.  This commentary was just published on the Commonwealth Magazine website.]

A CORE TENET of behavioral economics is that most of us are biased toward optimism. I plead guilty. Today’s Exhibit A of my optimism bias is the Republican federal tax cut legislation heading toward the desk of President Trump for his signature.

It is true that the tax cut legislation is rigged to disproportionately benefit rich corporations and wealthy individuals; it expands the federal debt by $1.5 trillion or more; it’s biased against blue states that provide better public services and education; yes, it’s the pits. And yet…

In at least two ways, this new tax cut law will present opportunities and advantages for progressives, one next year, and the other in the future when Democrats recapture control of the White House, Senate, and House of Representatives, as early as January 2021. In this column, I’ll discuss the first – the tax legislation’s repeal of the so-called “individual mandate” in the Affordable Care Act (ACA). In my next column, I’ll explain how the tax cuts may empower Democrats to do a lot of good public policy in the near future.

Dave Granlund / politicalcartoons.com

Here’s the first way. The tax cut legislation reduces the ACA’s tax penalties under the so-called “individual mandate” to zero. Despite repeated media reports that the law repeals the individual mandate, that’s incorrect. Straight repeal is not permitted under the Senate’s strict “budget reconciliation” rules under which the tax legislation is moving forward, but reducing the mandate’s monetary penalties to zero is kosher.

Many have predicted that disabling the individual mandate will fatally undermine the ACA.  That’s also incorrect. The 13 million people – with incomes between 0-138 percent of the federal poverty line – who got covered because of the ACA’s Medicaid expansion are untouched. Also, the 9 million between 139-400% of poverty who receive private health insurance subsidies will be largely unaffected. Continue reading “The Republican Tax Cut’s Silver Linings Playbook”

Questions for New Single Payer Advocates

[This commentary was posted by the Milbank Quarterly this week.]

Seeing, hearing, reading, and feeling the new grassroots ferment among progressive Americans for a single-payer health care system, my gut reaction is: I get it. As newly documented in Elizabeth Rosenthal’s book, An American Sickness,1 and the Commonwealth Fund’s report, Mirror, Mirror 2017,2 our health care system provides shockingly poor value and outcomes, and rests on a foundation of greed. It deserves fundamental change.

So why not start all over with single payer or Medicare for all? Before answering, let’s consider 4 critical questions.

Question 1: What have we learned from prior single-payer state ballot initiatives over the past 25 years that could inform future efforts?

Though most don’t remember, health care activists in 3 states had the temerity to place a binding single-payer initiative on their state ballot over the past 24 years: California in 1994, Oregon in 2002, and Colorado in 2016. Once every decade in recent history, a group has bet that the public is finally fed up and ready for change. Though initial public opinion polls in each state showed promising prospects, the final tally in each state was disappointing:

Year State % Yes % No
1994 California 27 73
2002 Oregon 21 79
2016 Colorado 20 80

The California vote happened only 3 months after the collapse of President Bill Clinton’s universal health care proposal. Many activists then asserted that if only Democrats had advanced single payer instead of Clinton’s wonkish contraption, reform would have prevailed. California provided a robust, timely, and failed test of that hypothesis. Similarly 22 years later, the Colorado initiative gave voters in that state a chance to endorse “real” reform above and beyond the incremental Affordable Care Act. Mission not accomplished.

In each case, single-payer advocates could not make the case to convince voters that the program would be financially sound. Ultimately, each attempt scared away each state’s bipartisan political and health care establishments (including leading hospital and physician associations).

To the new generation of single-payer advocates, what have you learned from these precedents, and what do you know that advocates in these states did not?

Question 2: What have we learned from Vermont’s failure to enact single-payer legislation between 2010 and 2014?

The years 2010 and 2011 were heady for Vermont single-payer advocates. A new Democratic governor, Peter Shumlin, backed by solid Democratic majorities in the State Senate and House, made state enactment of single payer his highest legislative priority. An independent analysis made the plan, including financing, seem like a no-brainer. The legislature agreed, enacting a new law in 2011 to establish the Green Mountain Health Plan, which would implement the ACA in 2014 and then a single-payer system by 2017. The fly in the ointment? The legislature and governor delayed unveiling their financing plan, including new taxes, until 2014.

Meanwhile, some things began to go wrong. State government’s ACA implementation, especially the health exchange website, was a disaster, undermining public confidence in their ability to manage the entire health care system. Also, Shumlin kept delaying release of a financing scheme because deeper analysis showed weaker financing. In the fall of 2014, Shumlin barely won reelection with a 47-46% margin against a Republican who made opposition to single payer his central campaign pledge.

In late 2014, Shumlin threw in the towel, abandoning the project rather than trying to convince Democratic legislators to embrace estimated new income taxes up to 9.5% and new employer payroll taxes up to 11.5%. Final estimates showed that the new taxes could make the program work financially, though with zero margin for error. In the end, Shumlin’s call was political; he could not justify sending his party over a cliff on such a weak and risky bet.

To the new generation of single-payer advocates, what have you learned from Vermont’s experience to inform a national campaign?

Question 3: Because the Achilles’ heel of single payer is financing, how can this be presented and managed in a way that avoids political collapse?

The new field of behavioral economics helps here. A core tenet is that people value hypothetical losses far more than hypothetical gains. If I promise Jane $100, she likely will believe it when she sees it. If I tell James that I’m going to take $100 from him, he’ll take me more seriously than Jane, and get his pitchfork ready the next time I come near him.

This has happened in previous attempts at health reform. Presidents Harry Truman and Bill Clinton lost big-time because the opposition overwhelmed advocates and scared the uncommitted. Presidents Lyndon B. Johnson and Barack Obama won their reforms only after sharply limiting the benefits of their proposals to the elderly and to the residual uninsured population, respectively. Republicans lost their attempts at repealing the ACA in 2017 because now they were making the promises and Democrats scared the heck out of people.

Single payer echoes the Truman and Clinton approaches of big system change for everyone, the opposite of the LBJ and Obama approaches. Even the unaffected heed scare stories of impending harm—witness the overwhelming opposition to the ACA in 2009-2010 by senior citizens who were only helped by the law.

To the new generation of single-payer advocates, how will you avoid this trap?

Question 4: How will payments to hospitals, physicians, and other medical providers be set to save money without alienating the medical establishment?

I know the response—we’ll pay them Medicare rates. If it’s good enough for Medicare, it’s good enough for everyone.

While this sounds good, it obliterates the essential structure of US health care financing today which is based on much larger payments from private payers, especially employer-provided health insurance plans. Attractive hospital and outpatient facilities as well as high salaries for physicians, nurses, and everyone else in medical care don’t come from Medicare or Medicaid rates. They come from private financing. Like it or not, single payer based on Medicare rates would trigger wrenching changes to US health care financing.

Before that would happen, power sources across the system—hospitals, physicians, drug and device makers, insurers, and boundless others—would use every tool in their bountiful toolboxes to provoke a cataclysmic political fight, far beyond anything experienced in California, Oregon, or Colorado. It’s hard to imagine a time when so much money would be at stake.

To the new generation of single-payer advocates, how can you pass single payer if most hospitals, physicians, and other providers are on the other side against you?

An extraordinarily broad coalition of Americans joined together to oppose Republican ACA repeal-and-replace plans with impressive impact. Most of this coalition can unite today and find common ground to address and fix the ACA’s many flaws, to advance better coverage, and to up the ante on cost control and delivery system reform.

Or, we can bet the house on single payer and risk replaying the catastrophic defeats in the Truman and Clinton eras. Count me as open to the conversation and deeply unconvinced.

References

  1. Rosenthal E. An American Sickness: How Healthcare Became Big Business and How You Can Take It Back .New York, NY: Penguin Press; 2017.
  2. Schneider EC, Sarnak DO, Squires D, Shah A, Doty MM. Mirror, Mirror 2017: International Comparisons Reflect Flaws and Opportunities for Better U.S. Health Care. New York, NY: Commonwealth Fund; 2017. http://www.commonwealthfund.org/interactives/2017/july/mirror-mirror/. Accessed September 18, 2017.

A Bipartisan “What’s Next” for U.S. Health Reform

[This past week, I was one of the co-authors of a consensus policy paper on short-term steps that would stabilize the ACA health insurance marketplaces and address some other urgent health policy priorities such as reauthorization of the Childrens Health Insurance Program (CHIP).  The paper was authored by a group of 9 policy experts (5 on the Republican/conservative side and 4 on the Democratic/progressive side).  While the ideas are not revolutionary, we show that bipartisan consensus is possible and offers hope for saner and more balanced policy — we hope!  Here is the paper below:]

The Congressional effort to repeal and replace the Affordable Care Act (ACA) has stalled, sparking urgent questions about what’s next and whether a bipartisan agreement could be achieved to address important U.S. health reform needs. We believe that critical matters relating to health reform must be addressed quickly and that bipartisan approaches are possible.

We are health policy analysts and advocates who join in this agreement. While we hold diverse political views and policy outlooks, we believe that health reform solutions exist that can transcend partisanship and ideology.

In this commentary, we describe our bipartisan agreement on five health policy matters that should be addressed by the end of the federal fiscal year, September 30. These recommendations are designed to provide stability in markets until a longer-term resolution can be achieved and, most importantly, to protect coverage and health care access for those relying on them now. Continue reading “A Bipartisan “What’s Next” for U.S. Health Reform”

MayDay! The ACA Is Still Alive and Still in Danger

Today is May Day and the ACA is still alive.  Donald Trump’s campaign boast that he would sign a bill repealing the Affordable Care Act (ACA/ObamaCare) on his inauguration day is long gone and forgotten.  House Speaker Paul Ryan and Senate Majority Leader Mitch McConnell’s gamble that by April 28th the ACA would be effectively decimated using the expedited budget reconciliation process proved to be a sucker’s bet.

Undeterred, White House and House operatives are trying by Wednesday to line up 216 votes—not to pass the Republicans’ American Health Care Act (AHCA) but to feign signs of progress to dampen the white-hot anger of the Republican base at their Party leaders’ inability to enact the ACA repeal promised since the law’s signing on March 23, 2010.  They want to take a third run at it this week and perhaps succeed after two prior failures.  Senate Republicans, meanwhile, are crossing their fingers hoping that the House fails, sparing the upper chamber the funerary duties.  For the Senate to advance ACA repeal now, a new and wholly unimagined bill would need to be constructed.

The level of legislative malpractice evidenced by Speaker Ryan and his team since January is staggering and perplexing.  They designed a bill that the Congressional Budget Office estimated would cause 24 million Americans to lose health insurance.  They advanced a proposal that provoked public opposition from the American Hospital Association, the American Medical Association, the American Nurses Association, AARP, and hundreds of other national organizations representing Americans with serious stakes in our health care system.  They invented a plan that generated unprecedented grassroots support for the ACA and fierce opposition aimed at them. For the first time, Ryan’s plan turned most Americans into ACA supporters. His legislation generated support from only 17% of Americans, an unheard of level of non-support.

Why did they do this and why do they persist?

Trump and Ryan both showed their hands in recent public statements linking ACA repeal with their tax cut agenda; Trump’s tax plan was released in one-page outline form this past week.  To Republicans, the ACA’s poison is not the insurance expansion that bears remarkable resemblance to the two public health insurance programs they have always loved: Medicare Part C or Medicare Advantage, and Medicare Part D, the outpatient prescription drug benefit. Continue reading “MayDay! The ACA Is Still Alive and Still in Danger”

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”

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”

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.