Revisiting the Land of the Individual Mandate

[This new commentary was just published by the Milbank Quarterly.]

The years 2013 through 2016 were excruciating for the Massachusetts Health Connector. In 2013, the Connector was among the nation’s most troubled federal/state health insurance exchanges, as it endured an epic collapse of its new website to help consumers purchase individual health insurance. Since then, it has taken a step-by-step and low-key “no news is good news” approach to rebuilding trust and credibility with its 252,000 clients.

Now the silent period is ending. In 2006, Massachusetts was the first and only state to enact an individual health insurance mandate, the essential model for the federal individual mandate included in the Affordable Care Act (ACA) in 2010 and implemented in 2014. In last December’s Tax Cuts and Jobs Act, President Trump and Congress neutered the ACA mandate by reducing the financial penalty to 0. Despite widespread reports to the contrary, the mandate was not repealed, and the law, with its mandatory reporting requirements, remains on the books.

Thus, Massachusetts now returns to the spotlight as the nation prepares to examine the impact of the federal action, testing 1 state’s experience against that of the other 49. In 2015, the last year for which tax data is publicly available, only 3% of adult tax filers in Massachusetts reported not having insurance meeting state standards, corroborating other data sources indicating that it has the lowest rate of uninsurance in any state (the most recent US Census data shows Massachusetts at 97.5% coverage). Depending on an uninsured person’s household income, the monetary penalty ranges between $21 and $96 for each month without coverage. As of early February, at least 9 other Democratic-leaning states are considering adopting a similar mandate. Continue reading “Revisiting the Land of the Individual Mandate”

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.