Explaining our Health Care Dilemma to the World

I co-wrote the article below for the British Medical Journal with John Park, a Kennedy Scholar at the Harvard TH Chan School of Public Health:

America’s HealthCare Dilemma

The insurance of at least 22 million Americans hangs in the balance

The election of Donald Trump as 45th president of the United States has triggered concerns in many globally important areas of public policy, including climate change. But for Americans, one of the most unsettling challenges is the future of domestic healthcare policy and the fate of the 2010 health reform law, the Affordable Care Act (ACA).

For 45 years, the US healthcare system has been accurately characterized as the most expensive among nations in the Organization for Economic Cooperation and Development (OECD), as mediocre regarding quality and effectiveness, as inadequate in that it left nearly 50 million Americans uninsured, and as substandard in core outcomes such as infant mortality and life expectancy. In short, the only category at which Americans seemed to excel was in spending the most money.1

Between 2005 and 2008, many sectors in American society became vocal in calling for comprehensive healthcare reform to address failings in access, quality, cost, and outcomes. Between January 2009 and March 2010, new President Barack Obama worked with hefty Democratic majorities in the US Senate and House of Representatives to fashion comprehensive reform to tackle these deficiencies, signing the ACA on 23 March 2010. Though some Republican members of Congress initially expressed support for reform, objections to the Democratic approach and political resistance from their grassroots left zero Republican supporters by the time that the ACA was signed. Continue reading “Explaining our Health Care Dilemma to the World”

Pre-Election Reflections on Health Reform in the 2016 Campaign

[This post appeared in the Health Affairs blog on November 7 2016.  Happy election day, everyone!]

We are nearing the grand finale of our long and disheartening election opera, one we dare not ignore because the outcomes matter so much. While the election results will not be determined by public reactions to the Affordable Care Act, the ACA’s fate will be mightily determined by Tuesday’s outcomes. What have we learned about our collective health future over the past 18 months and what might this mean for our health system’s future?

Public opinion on health reform is as frozen today as it was in spring, 2015

Kaiser monthly tracking polls show reliably unfavorable attitudes toward the ACA, slightly beating favorables, and stuck since 2014 in 40 percent purgatory. The advantages millions of Americans feel from ACA insurance coverage expansions and other access reforms are balanced by those who now blame the ACA for everything bad that happens in health care. The misnamed Pottery Barn rule—“if you break it, you own it”—applies here even though the dish was broken well before the ACA. Beyond this, if there is one thing on which both sides of the new Republican divide concur, it is a deep hostility towards ObamaCare. The election cycle seems to have only hardened these views.

kff-fav-unf

 

 

 

 

 

 

The essential differences between Democrats and Republicans are now more clear

We know more about the preferences of both parties with respect to the ACA than we did 18 months ago. Hillary Clinton, Donald Trump, and House Speaker Paul Ryan, have released health reform planks that clarify their intentions — regardless of Congressional feasibility.

Clinton wants to maintain and strengthen the ACA by improving premium affordability and by addressing excessive cost sharing in the Exchanges and beyond. She has an eight-point plan to address pharmaceutical prices. She will emphasize women’s health, and much more. Her campaign has articulated the first full agenda of any leading Democrat to improve and advance the ACA, helping to define the arena of possibility, whether far-fetched or not.

After early teasing about his admiration for the Canadian and Scottish single-payer systems, Trump embraced standard Republican orthodoxy on ObamaCare, most recently announcing his intention to call a special Congressional session as soon as possible to repeal the law. Two independent research institutes (Committee for a Responsible Federal Budget and the Commonwealth Fund) have concluded that Trump’s agenda, if implemented, would result in 20 million Americans losing health insurance and would increase the federal deficit by $330-550 billion over 10 years.

Meanwhile, Speaker Ryan announced in September his intention—if Republicans control both houses of Congress and the White House in January—to expedite budget reconciliation legislation that would repeal as much of ObamaCare as possible. Though Ryan’s plan is more ambitious than Trump’s, of the latter’s seven health policy planks, five also show up on the Speaker’s agenda.

The final week’s fireworks over premium increases in the individual health insurance market only emphasize that the political volatility of the ACA/ObamaCare has not diminished at all.

Differences involving the ACA are not about facts or data, but about fundamental values

One of my favorite political scientists, Deborah Stone, in her book Policy Paradox, writes that much of the policy process involves debates about values masquerading as debates about data and facts. That sure describes the past eight years of health reform. As my colleague Robert Blendon showed in his pre-election special report for The New England Journal of Medicine:

The political parties fundamentally differ over the role the federal government should play in intervening in the U.S. health care system, (and) the desirability of the federal government moving ahead with future efforts aimed at universal coverage…

blendonnejm

Source: POLITICO, Harvard T.H. Chan School of Public Health Poll. Voters and health care in the 2016 election. September 14–21, 2016.

The notion that these differences might be leavened, for example, by changing the age-rating bands (the maximum amount an insurer can charge in premiums for young people versus older enrollees) in the Exchanges from three-to-one up to six-to-one, is delusional. Six and a half years after its signing, the ACA has yet to become settled policy because the differences are simply too deep and neither side of the political divide can risk the backlash of surrender.

Republicans don’t want to fix the ACA car at any cost; they are determined to smash it

The excessively high premium increases in 2017 in the ACA Exchanges, more than anything, are tied to elimination in 2017 of risk corridors and reinsurance, as well as the undermining of risk adjustment. This past summer, Alaska’s Republican Legislature established its own reinsurance mechanism to stabilize rates, and immediately saw premium increases drop from over 40 percent to under 10 percent.

In my time as a member of the Massachusetts House of Representatives (1985-1997), I learned that when political partners like and respect each other, the most difficult challenges could be met with seeming ease; and conversely, when parties disliked and disrespected each other, the easiest chores were impossible to achieve. And thus it is with the ACA Exchanges, eminently fixable technically, and utterly unfixable politically.

And ACA demolition is advanced with no clearly defined replacement alternative. Yes, Speaker Ryan advanced a health reform agenda this past summer; yet he and his team did not put their ideas into legislative language that could be scored by the Congressional Budget Office, perhaps because they knew that the results on both lost insurance coverage and rising costs would turn the public against them.

“The future, like everything else, is no longer quite what it used to be.” (Paul Valery, 1937, not Yogi Berra).

As I write this on November 3rd, the most likely outcome from November 8 is divided government, with a Senate majority hanging by a thread. (Please recall that Senator Al Franken (D-MN) took his U.S. Senate seat for the first time in July 2009 after an eight-month recount process.) Republicans know that the electoral map in 2018, all things being equal, will offer substantial gains in both the Senate and the House, particularly if their political base is pleased. Democrats know that they will need to deliver on at least some of their promises, and not allow the signal accomplishment of the Obama Administration to fall apart.

Dare I say it: we’re going to need some statesmanship at a time when that commodity is in short supply.

The Choices on Health Reform in the US Presidential and Congressional Elections

The commentary below was published in JAMA Internal Medicine online on October 10 2016 and was written by me and David K. Jones from the Boston University School of Public Health:

Although the outcomes of the US Presidential and Congressional elections in November 2016 will not be determined by attitudes toward the Affordable Care Act (ACA), the results will likely determine its long-term fate. As was the case in 2008 and 2012, the electorate’s decisions on whether the Republicans or the Democrats control the White House, the Senate, and the House of Representatives will have fundamental consequences for the future of national health reform.

A Republican victory that includes that party’s control of the White House, Senate, and House of Representatives would likely augur huge shifts in national health policy. A Democratic victory that included the White House and a Senate majority would likely further embed the ACA into state and federal health policy, and perhaps lead to further expansion and reforms. More than 6 years after President Barack Obama signed the legislation into law in 2010, the ACA has yet to become settled policy.

The Republican Agenda

Over the past 4 years, Republican members of Congress and conservative think tanks such as the American Enterprise Institute and the Manhattan Institute have advanced numerous proposals to repeal and replace the ACA. As the final stages of the 2016 campaign approach, 2 plans stand out: Republican presidential candidate Donald Trump’s agenda as outlined on his campaign website,1 and the House Republican leadership plan released by Speaker Paul Ryan (R-WI) in June 2016.2 Continue reading “The Choices on Health Reform in the US Presidential and Congressional Elections”

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 “Obama, Clinton and the New Public Option”

Bernie Sanders and Hillary Clinton on Health Care – Who’s Got the Plan?

It’s funny how things turn out on the campaign trail. Since all Republican presidential candidates pledge to repeal the Affordable Care Act/ObamaCare, they have little to argue about. The fireworks are among Democrats as Hillary Clinton and Bernie Sanders argue the future of US health reform and, specifically, the merits of Sanders’ new single payer/Medicare for All scheme, released Sunday evening hours before the Democrats’ final pre-primary debate.

Clinton, fighting a Sanders surge in the Iowa and New Hampshire Democratic primaries, has been landing punches to throw his momentum off balance. Meanwhile, Sanders keeps humming the single payer tune that the Democratic base adores (see the Kaiser Poll below), offering some new melodies and riffs in his revised plan.

single payer 1

Sanders’ proposal matters because it shows how progressive thinking has shifted and because it calls into question whether Democrats have the staying power and political will to defend one of their principal accomplishments in the past 50 years, the ACA. Here are key points about the Sanders plan: Continue reading “Bernie Sanders and Hillary Clinton on Health Care – Who’s Got the Plan?”