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”

House Republicans Show Their Hand on ACA — and It’s Not Good

[This February 26 2017 commentary was published on the Commonwealth Magazine website.]

LATE LAST WEEK, Politico released a leaked 105-page draft bill defining the House Republican plan to repeal/replace/repair/re-whatever the Affordable Care Act/Obamacare. The draft legislation was dated February 10, so likely it’s already out of date, though it is the best indication yet of their rapidly evolving intentions and fits with many of their prior recent proposals. So a big GOP move is getting close, and it’s not good. What’s important?

First, the ACA’s generous coverage expansion (for many, not all) through Medicaid expansion and private insurance subsidies would be drastically curtailed, leaving most of the 22 million who got either form of coverage without an affordable option.

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Second, not only is the ACA Medicaid expansion repealed by 2019 (11 million people and counting), the plan would replace current Medicaid financing with a “per capita cap” by 2019, shrinking funding by hundreds of billions, perhaps more, over 10 years. Continue reading “House Republicans Show Their Hand on ACA — and It’s Not Good”

“It has saved my life.” Voices from Ohio on Medicaid Expansion

[This commentary was first published on February 15 on the Commonwealth Magazine website:]

OHIO IS ONE of 31 states that expanded Medicaid as permitted by the Affordable Care Act/Obamacare for nearly all low-income citizens. The state’s Republican governor, former presidential candidate John Kasich, has been among the most vocal proponents of the expansion on the Republican side and has taken a lot of grief for it from ACA opponents.

In early January, the state released an evaluation of the impact of the expansion, “Ohio Medicaid Group VIII Assessment: A Report to the Ohio General Assembly“. (Group VIII is the legal name for the ACA Medicaid expansion population.)

ohio-medicaid

The report has a host of quotes from interviews with individuals who benefited from the expansion, and I include a selection of these quotes below, along with a section from the report’s overall summary. This is what Medicaid expansion has meant to real Americans:

“It gives me peace of mind knowing that I don’t have to pay for the medical insurance, and it saves me money being able to afford food and utilities and everyday things you need in life.”

“It’s been a blessing and I thank God that I have Medicaid because I no longer have large payments and I can get my Medicaid medicines.”

“More freedom. Less worries. I was an addict for 3 years before getting Medicaid. Because of Medicaid I’m not an addict.” Continue reading ““It has saved my life.” Voices from Ohio on Medicaid Expansion”

Welcome Back to the Medical Underwriting Circle of Hell

[This commentary was posted today (2-15-2017) at RealClearHealth.]

All leading Republicans who are committed to repealing all or key parts of the Affordable Care Act (ACA) also emphasize their commitment to maintaining the law’s most popular part: banning pre-existing condition exclusions and medical underwriting by preserving the ACA’s (also known as Obamacare) policy of “guaranteed issue.” But the fine print in Republican proposals betrays that commitment, including legislation filed on January 26 by House Energy and Commerce Committee Chairman Greg Walden (R-OR) threatening health security for tens of millions of Americans.

Medical underwriting is the insurance industry practice of issuing and pricing health insurance based on an individual’s current or prior medical condition. Insurers use medical underwriting and pre-existing condition exclusions to avoid covering anyone who might cost them money. The Walden bill, called the “Preexisting Conditions Protection and Continuous Coverage Incentive Act,” pretends to continue the ACA’s ban on medical underwriting, but would, in reality, do the opposite.What are pre-existing conditions that can prevent you from obtaining coverage?

What are pre-existing conditions that can prevent you from obtaining coverage? Here is a list of hundreds that are used to exclude or limit health insurance: acne, cancer, domestic violence, leukemia, pregnancy, sleep apnea, and much more. Continue reading “Welcome Back to the Medical Underwriting Circle of Hell”

Vive la ACA Resistance!

[This commentary was published on the Commonwealth Magazine website last week.  If you are supportive of what the Affordable Care Act has achieved and want to help defend it — the time is NOW.  Please go to: http://protectmycare.org/ to learn how you can help, now. Everyone.  Please.]

A NEW REPUBLICAN-CONTROLLED Congress is in place. And for the sixth time, the Affordable Care Act (ACA) is facing extinction. Indeed, a gripping narrative history of the ACA/Obamacare could be written focused only on its numerous near-death experiences. Maybe the sixth time will be the curse, and maybe not. Let’s recall.

One, in January 2010, the loss of the 60th Democratic vote in the US Senate via the election of Republican Scott Brown to the seat formerly held by Massachusetts Sen. Edward Kennedy was almost universally assumed to be the end of the road for President Obama’s health reform agenda. He signed the ACA into law two months later.vive-la-resistance

Two, in June 2012, by a single vote, the US Supreme Court upheld the constitutionality of the ACA’s individual mandate and, by extension, the ACA. On the day of the decision, premature news accounts by CNN and Fox News erroneously reported that the court had overturned the law.

Three, in November 2012, thorough ACA repeal would have followed an electoral win by Republican Mitt Romney in that year’s presidential election, well before full implementation in 2014.

Four, between October-December 2013, catastrophic launches of the federal and state Health Exchange websites temporarily made the law a national laughingstock facing stillbirth at its most critical setup moment. The debacle was accompanied by a three-week October shutdown of the federal government in a final Republican spasm to prevent January 1, 2014, implementation.

Five, in June 2015, a second potentially fatal lawsuit that reached the US Supreme Court was laid aside by a 6-3 vote.

Six and lastly, the November 2016 federal elections represented the final life-threatening challenge.  An expected presidential victory by Democrat Hillary Clinton would have sealed the law’s lifespan at least until 2021. Instead, Republican Donald Trump’s victory now is leading many, once again, to predict the law’s effective demise this year.

Except, it ain’t necessarily so.  Here are three reasons why.

First, the Republicans’ ACA playbook is riddled with contradictions and dissent over their “repeal and delay” strategy.  Will delay last two, three, or four years? Once they repeal the law’s financing, how can they pay for even a minimal replacement? Will they do one replacement or a series of replacement bills? How can they keep private insurance companies from abandoning the individual insurance market in soon-to-be demolished health exchanges?  How will they keep preposterous promises that their still-unknown replacement will provide better coverage at lower cost for everyone who has been helped by the ACA? How will they keep Republican governors in line as they seek to slash Medicaid spending by approximately $1 trillion dollars over 10 years? These are just for starters.

For a devastating look at the contradictions in “repeal and delay,” see this week’s Health Affairs blog by conservative analysts Joseph Antos and James Capretta: “The Problems with ‘Repeal and Delay.’” “The most likely end result of ‘repeal and delay,’” they write, “would be less secure insurance for many Americans, procrastination by political leaders who will delay taking any proactive steps as long as possible, and ultimately no discernible movement toward a real marketplace for either insurance or medical services.”

Second, as Americans now focus on Republican non-plans and non-answers, public opinion is turning against them. Recent Kaiser Family Foundation polling shows that even Trump voters – who are far more chronically ill and needy than Clinton backers – support nearly all of the ACA’s essential building blocks except for the individual mandate, and oppose repeal without a replacement plan. As Noam Levey from the Los Angeles Times has shown, not a single nationally recognized patient or health care provider organization supports the Republican repeal agenda. Only the fringes of the Tea Party stand by their sides in this backward quest.

Third, while defenders of Republican drive to end coverage for between 22 to 30 million Americans are few and far between, broad resistance to the first major policy thrust of the Trump era is building.  A broad-based “Protect Your Care” coalition is spearheading national resistance, collaborating with President Obama and congressional Democrats and leading to a day of demonstrations across the nation on January 15. Hospitals, doctor and medical student groups, insurance companies, community health centers, and other health care stakeholders are making clear the damage now threatening the entire US health care system. Meanwhile, former Democratic congressional staffers have developed a blueprint for broad-based resistance to the Trump/Republican agenda, called “Indivisible.”

Republicans may win, though they will rue the day that they set in motion destabilization of the nation’s health care system. Around the globe, universal health coverage is now recognized not just as something governments do to be nice to their people, it is understood as an essential precondition for healthy societies and healthy economies. Over the past eight years, the United States has been moving forward to join the universal consensus of advanced nations, most of whom are far less affluent than the US.

Whether Republicans succeed or fail is not just up to them. It is now up to all Americans. Vive la ACA resistance!

Five Affordable Care Act Questions for the GOP

[This commentary was published today on the website of Commonwealth Magazine.]

SO, REPUBLICANS ARE planning a major blitz to repeal and delay/replace/collapse the Affordable Care Act/ACA/ObamaCare. I’ve got five questions to ask leaders of the Grand Old Party.

First, if your guarantees are honest that your replacement law will be better than the ACA, why not share real numbers?

President-elect Donald Trump, Speaker Paul Ryan, and Majority Leader Mitch McConnell have each promised that their ACA replacement will cover as many Americans as the ACA with higher quality and lower costs. Bully for that!

Here’s the problem. None of the plans you’ve produced, including the 2016 Reconciliation bill, Trump’s platform, Ryan’s Better Way, Health & Human Services Secretary designee Tom Price’s Empowering Patients First plan, or others from Republicans and conservatives, comes close. Except for this year’s reconciliation bill, none has been submitted to the Congressional Budget Office for a score. Reputable analysts peg the drop in insured lives between 20-30 million currently insured.wash-monu

Your message is “trust us.” Would businessman Trump take such a deal?

Second, when you promise to continue “guaranteed issue” of health insurance with no-pre-existing conditions or medical underwriting, why do you always fail to mention the fine print?

Trump, Ryan, and other Republicans’ statements are clear – any reform will maintain “guaranteed issue.” Yet your written plans tell another story – guaranteed issue will be kept only for persons who maintain “continuous coverage” (undefined). This means if you lose your insurance and have a coverage gap beyond the allowed time, you will be newly subject to medical underwriting and pre-existing condition exclusions for an unspecified period (forever?).

How many people might fall into this new medical underwriting Circle of Hell (CoH)? Start with 28-29 million currently uninsured, add the estimated 20-30 million increase because of Republican plans to eliminate income-based premium subsidies. We start at 48-58 million Americans, and the numbers will only grow as more fall into the medical underwriting CoH.

This is detailed in numerous replacement plans, including Ryan’s. Yet you never mention this life-important detail when talking with media who buy your line that you will continue the ACA’s elimination of pre-existing conditions for everyone. Untrue.

Third, what will you do about enormous losses for those dealing with substance abuse and mental health needs under your plans?

Most Americans don’t realize that the ACA is the biggest law ever in covering Americans for substance abuse and mental health services (aka: behavioral health). It’s true. ACA guaranteed issue means no one can be denied insurance because they had or have substance abuse/mental health problems. Bans on lifetime and annual benefit limits allows countless persons with expensive substance abuse or mental health disorders to keep covered.  Requiring insurers to cover 10 “essential health benefits” insures that nearly all Americans have behavioral health coverage (#5) PLUS prescription drugs (#6) to treat their disorders.

All Republican plans – Trump, Ryan, Price etc. – propose eliminating “essential health benefits.” They propose eroding guaranteed issue (see above) and canceling elimination of annual benefit limits. So, the ACA’s enormous advances for  mental health and substance abuse would become major losses under Republicans’ plans. I’m not sure you get this at all.  I am certain most Americans have zero idea of this and they will strongly object when they find out.

Fourth, why are you so mean to the nation’s hospitals? 

In crafting the ACA, America’s hospitals committed a mortal sin in Republicans’ eyes by making a deal with President Barack Obama and the US Senate. In exchange for Democrats’ commitment to get as close to universal coverage as politically possible, hospitals agreed to $155 billion in federal payment reductions between 2010-19 (now about $350 billion between 2016-2025). They did this to stop being the default caretakers of America’s uninsured.

Now Republicans plan to repeal the ACA’s new taxes on wealthy Americans, on drug, medical device, and health insurance companies, even on indoor tanning salons! And, they plan to leave in place the $350 billion in payment cuts to hospitals even as their policies will send as many as 30 million recently insured Americans back into the ranks of the uninsured and back to America’s emergency departments.

The American Hospital Association and the Federation of American Hospitals, who brokered the 2009 deal, wrote a letter on December 7 to Republicans: “…any repeal legislation … must include repeal of the reductions in payments for hospital services embedded in the ACA.” Sounds reasonable to me, but maybe not to others because if Congress sends the money back, it will raise Medicare’s costs for the next decade and beyond, resulting in premium increases for Medicare enrollees across the nation, and shortening the lifespan of the Medicare Hospital Trust Fund (now solvent through 2028) by years. Sad!  (Read this excellent Kaiser Health Policy Brief for more details on the impact of ACA repeal on Medicare.)

Fifth, why don’t you just fix the ACA exchanges instead of killing them?

A parable: Last summer, Alaska realized that premiums in its health exchange and individual health insurance market would be rising in 2017 by over 40 percent. In response, the Republican legislature established a state reinsurance pool to protect insurers against high losses; after passing the law, insurance companies dropped their premium increases to about 7 percent.

Some health insurance exchanges (i.e., California, New York, Massachusetts) are working well, and some are having high rate increase problems. These problems are fixable with sufficient political will to address them.  The problem is that Republican lawmakers don’t want fixes – they want repeal. In 2014, 2015, and 2016, exchange premium increases were below projections. In 2017, they have risen at high rates in most states because of the end of rate protections known as “risk corridors” and “reinsurance” as well as the underfunding of “risk adjustment” in the ACA. All of these “3Rs” are permanent features of the Medicare Part D prescription drug program that Republicans support there and despise in the ACA.

These exchange problems are fixable. Yet you refuse to support them and fix the problems because that would undermine your case for ACA repeal.

These are my top five questions right now. Any answers, my friends?

Assessing President Obama’s Health Legacy

I was asked last August to write an assessment of President Barack Obama’s public health legacy for the January issue of the American Journal of Public Health.  My drop-dead deadline was mid-October when the overwhelming consensus indicated a likely electoral victory for Hillary Clinton who would have continued President Obama’s directions.

Funny how things can turn so suddenly, as they have with the electoral college victory of Donald Trump and the emergence of a new and conservative federal Administration.  Some of my commentary — just released — still seems appropriate, even if a big chunk of Obama’s legacy is repealed.

So here’s my official appreciation of what Barack Obama has done for Americans’ health and America’s health care system.  (If you look at the AJPH, you will see two companion editorials, one by Drs. Steffie Woolhandler and David Himmelstein critiquing the Obama legacy from the left, and one by Dr. David Sundwall with a critique from the moderate right.


A CONSEQUENTIAL EIGHT YEARS FOR HEALTH CARE AND PUBLIC HEALTH

Every modern US president since Harry Truman has impacted the nation’s health through his successes and failures.1 Arguably, Lyndon Baines Johnson created the most important legacy through the establishment of Medicare and Medicaid in 1965. Whether Barack Obama’s health achievements equal or exceed those of LBJ is a judgment best left for historians. At this point, it is reasonable to conclude that the Obama public health legacy will be deep, broad, and wide.barack-signature

Obama’s landmark achievement, the Affordable Care Act (ACA; Pub L No. 111–148), along with related enactments, assumes outsized significance in the real world and in this commentary. In addition, many other laws, regulations, executive orders, and other actions contribute to a compelling Obama public health record. In this brief overview, I consider the ACA and the President’s other public health accomplishments.

From the ACA to Obamacare

Although the ACA, to date, has fallen far short of the public health community’s expectations on many fronts, it is close to the most ambitious health reform law that could have been achieved in the 2009–2010 US Congress, or in any other modern Congress for that matter. Also, the ACA is still only six years old. The 1935 Social Security and 1965 Medicare–Medicaid laws initially fell well short of their respective visions, and only later matured into their current recognizable forms after decades of subsequent improvements. So it is and will be with the ACA, born in a contentious and madly partisan legislative environment, with many improvements still needed to fully realize its ambitious goals. That realization should not denigrate the law’s accomplishments.

On access, more than 20 million formerly uninsured Americans have obtained health coverage, and the US rate of uninsurance has dropped to the unprecedented low rate of 8.6%.2 Coverage gains have disproportionately benefitted those most in need, especially lower income, non-White, and younger adult households. The shameful health insurance practices of medical underwriting and preexisting condition exclusions, as well as annual and lifetime benefit limits, have been abolished. Medicaid now makes quality and affordable coverage available to nearly all low-income Americans in the 31 states that have adopted the ACA expansion; over time, the 19 other states will follow. Although the work is far from done, this is extraordinary progress after so many decades of trying and failing.

The content of health insurance in all markets has been improved markedly. The ACA’s Title I guarantees that nearly all health insurance policies include 10 essential health benefits including, for example, mental health and addiction services, as well as prescription drugs. Another section requires that all health insurance policies must offer all clinically effective preventive services such as vaccines and cancer screenings that are recommended by the US Preventive Services Task Force, and with no cost sharing. Many millions more than the formerly 20 million uninsured have benefited from the ACA’s access and coverage provisions.

On transforming medical care, the ACA has reset the US health system irreversibly on a course away from wasteful and inefficient fee-for-service payment toward value-based models that reward quality, effectiveness, patient centeredness, and population health management. Accountable care organizations, patient centered medical homes, bundled payments, readmission, and hospital-acquired condition penalties—all these and more have become part of the nation’s emerging accountable care and “triple aim” landscape. Implementation of electronic health records has advanced with impressive speed and reach, as more than 80% of nonfederal acute care hospitals have adopted basic electronic health records with clinician notes. Although partisan bickering slows the continuous policy improvement of most ACA provisions, the 2015 Medicare Access and CHIP Reauthorization Act (MACRA), approved by the Republican-controlled House and Senate and signed by President Obama, only expands and deepens the ACA’s direction toward alternative payment models.

Yet another ACA landmark is the major expansion of federally qualified community health centers that now serve more than 24 million Americans at 1375 centers in 9200 communities, as well as the National Health Service Corps that provides medical student debt relief in exchange for service in underserved communities. As of 2015, 9600 Corps clinicians were providing primary care services, more that twice the number of 3600 doing so in 2008.

Beyond the ACA

Any list of the Obama Administration’s key health gains must include groundbreaking achievements in environmental health protection. The successful negotiation of the Paris Agreement on climate change, formally ratified in October 2016, for the first time has set the global community on a low-carbon course. Additionally, the Obama Administration’s numerous initiatives to limit carbon and other forms of pollution from power plants, cars, trucks, homes, and businesses are changing fundamentally how Americans consume energy, enabling the nation to meet its environmental goals in ways that will save countless lives. For example, the Environmental Protection Agency’s 2013 regulation on “National Ambient Air Quality Standards for Particulate Matter” will prevent thousands of premature deaths of elderly and young children from cardiovascular and respiratory illnesses caused by soot pollution.

Smoking is still the nation’s leading cause of preventable death. The 2009 signing of the Family Smoking Prevention and Tobacco Control Act, giving the US Food and Drug Administration authority to regulate nicotine as a controlled substance, was only the most public evidence of progress. The 2009 federal tobacco tax increase of 62 cents per pack, included in the reauthorization of the Children’s Health Insurance Program, combined with the “Tips from Former Smokers” campaign launched by the US Centers for Disease Control and Prevention, were among many initiatives that have contributed to major declines in both adult and adolescent smoking rates, including a drop among adults from 20.6% in 2009 to 15.3% in 2015.3

Regarding nutrition and food policy, the Obama Administration has reformed essential federal nutrition programs that provide a critical safety net for millions of American children and families. Lead by the US Department of Agriculture, for the first time in decades, the most current dietary science is being applied to nutrition programs. More than 50 million children now have healthier food environments at school. Because of new food standards, nearly four million schoolchildren have access to nutritious meals each day in summers, and eight million low-income women, infants, and young children receive improved WIC food packages.

Unknown to the public has been massive upgrading and professionalization of emergency response systems in the United States and globally. Two National Health Security Strategy Plans (NHSS), 2010 to 2014 and 2015 to 2018, have galvanized national efforts to minimize the health consequences of large-scale emergencies in response to the deficiencies evidenced by the tragedies of the 9/11 terrorist attacks in 2001 and Hurricane Katrina in 2005, to achieve a “health-secure and resilient nation.”4 The work’s impact can be seen in the US government’s response to national and global health security threats over the past eight years such as the 2009 influenza pandemic (H1N1), Middle East respiratory syndrome (MERS), the West African Ebola epidemic, and the current Zika virus threat. This new infrastructure helped to address health security threats from recent international crises such as the 2010 Haitian earthquake, the 2011 Japanese tsunami and nuclear power plan incident, and the 2013 Philippines typhoon.

Space constraints do not permit a thorough presentation of the public health achievements and progress by the Obama Administration. Such a full list would also describe: national and global progress in addressing the HIV-AIDS epidemic; fundamental changes in behavioral health financing and access including progress in addressing the advance of the opioid epidemic; adoption by numerous federal agencies of social determinants of health approaches in housing by the US Department of Housing & Urban Development and in transportation by the US Department of Transportation; major declines in adolescent pregnancy rates; unprecedented attention to the health needs of lesbian, gay, bisexual, transgender, and questioning communities; and much more.

Conclusion

Every Presidency leaves a unique record and legacy of accomplishments and shortcomings, of wins and losses.  Noteworthy during the Obama years has been the extraordinary number of initiatives, programs, experiments, and demonstrations that move moved the needle toward greater access, quality, equity, effectiveness, and efficiency in important matters relating to health care and public health.  Wherever Barack Obama lands in the historic hierarchy of significant and positive contributors to health, the extraordinary efforts made by him personally and by his talented, dedicated, and principled Administration have set a high bar and model for all who follow.  The Obama era has been a consequential eight years, and the Administration’s impact has been overwhelmingly for the better for the American people and for the people of the world.

References

1. D Blumenthal, J Morone. The Heart of Power: Health and Politics in the Oval Office. Berkeley, CA: University of California Press; 2010.
2. K Avery, K Finegold, A Whitman. Affordable Care Act has led to historic, widespread increase in health insurance coverage. ASPE Issue Brief. US Dept of Health and Human Services. September 29, 2016. Available at: https://aspe.hhs.gov/sites/default/files/pdf/207946/ACAHistoricIncreaseCoverage.pdf. Accessed October 11, 2016.
3. Early release of selected estimates from the National Health Interview Survey, 2015. National Center for Health Statistics. Available at: http://www.cdc.gov/nchs/data/nhis/earlyrelease/earlyrelease201605_08.pdf. Accessed October 11, 2016.
4. Assistant Secretary for Preparedness and Response. National Health Security Strategy and Implementation Plan 2015–2018. US Dept of Health & Human Services. Pg. v. 2014. Available at: http://www.phe.gov/Preparedness/planning/authority/nhss/Documents/nhss-ip.pdf. Accessed October 11, 2016.

The Future of Public Health under President Trump

[The Q&A below was published in Harvard media this past week.]

How might the election of Donald Trump as the next U.S. president impact public health over the next four years? John McDonough, professor of the practice of public health at Harvard Chan School, who worked in the Senate on the passage of the Affordable Care Act (ACA), offers his perspective in this Q&A.

mcdonough-head-shot
John McDonough

Many are worried that Obamacare will be in deep trouble—and likely be repealed—once Donald Trump is in the White House, working with Republican majorities in both the House of Representatives and the Senate. A week after the election, Trump appears to be hedging on his prior pledge to completely do away with the health reform law. What do you think will happen to the ACA—and to the millions of people who gained health insurance because of it?

The likelihood for total 100% repeal of the ACA is unlikely for two reasons: One is that this would have to be accomplished through regular legislative order in the U.S. Senate and Republicans would not be able to attract the necessary eight votes needed from Democratic senators to do this. Of course, if Republicans choose to abolish the filibuster, that would change. A second reason that repeal is unlikely is that many Republicans appreciate many non-controversial provisions in the ACA and repealing them would be backward steps they would not want to make happen.

Instead, and for now at least, Republicans appear to be moving toward a two-track process of “repeal and replace.” Repeal of the ACA’s essential health insurance coverage provisions, as well as the new taxes that financed the ACA’s expansions, could be achieved through the special “budget reconciliation process,” which only requires 51 votes for passage and cannot be filibustered. This would take some months to achieve, and is doable as long as 50 of the 52 Republican senators are willing to vote to eliminate coverage for as many as 22 million Americans—the number newly insured under the ACA—and their willingness to do that is not yet certain. Republicans did vote to repeal the most important parts of Obamacare in January of this year, but they did it knowing that President Obama would veto the measure. It would be a different vote knowing that President Trump would sign it.

Replacing the ACA with some other sort of health care law would be far more difficult because that legislation would need to proceed through regular legislative order and could and would be filibustered by Democrats, thus blocking the legislation. So it is conceivable that repeal could happen and replace might not follow, which would leave the up-to-22 million most at risk in a most difficult situation.

It’s been reported in the media that President-elect Trump may consider keeping some of the ACA’s more popular provisions, such as the requirement that insurance companies not deny coverage to people with pre-existing medical conditions, or that children up to age 26 can be covered under a family’s health plan. How do you think this might play out?

House Speaker Paul Ryan and House Republican leaders, in their “Better Way” document on repeal and replace last summer, indicated that they would continue the ACA’s “guaranteed issue” provisions—those making it illegal for insurers to deny anyone coverage because of health status, age, gender, or other factors—though only for those who are able to maintain “continuous coverage” with no or only short-term coverage breaks. For the millions of Americans who find themselves unable to afford coverage for some period of time, Republicans would, by their own words, return pre-existing condition exclusions and medical underwriting—charging the sick higher prices than the healthy. The provision for children up to age 26 being able to stay on parent’s health insurance policies is most likely not to be repealed.

How might the new president’s policies impact women’s health? He has said he would nominate a conservative Supreme Court justice who would be in favor of a pro-life agenda. Could this lead to Roe v. Wade being overturned? What other ways might women’s health be impacted under the Trump administration?

Even with a Trump appointment to the U.S. Supreme Court, there are five current votes, including Justice Anthony Kennedy, opposed to a Roe v. Wade repeal. So President Trump would need at least one additional replacement of those five to have a chance at repeal.

Other aspects of women’s health coverage are at risk because of Republican plans to repeal large portions of the ACA. Republicans want to return all discretion over required benefits to states, including the ACA’s mandates on benefits such as birth control, mammography, prescription drugs, behavioral health, and much more. So it’s possible that women could lose coverage for services that are currently free, such as contraception, mammograms, folic acid supplements during pregnancy, and screenings for gestational diabetes, sexually transmitted diseases, and cervical cancer.

Trump broke with conservative orthodoxy when he said that he’s in favor of Medicare being able to negotiate drug prices. He also has said that he would take on the Big Pharma lobby in order to reduce high prescription drug costs. Do you think he’ll be able to follow through on these pledges?

President Trump’s administration would only be able to negotiate drug prices or make other significant changes in pharmaceutical policies with the consent of Congress, which is most unlikely to provide that authority to him.  Also, though the health policy section on his campaign website included drug-related proposals, the health policy section on his presidential transition website includes no mentions of these.

There were a number of health-related ballot initiatives across the nation. Three states, including Massachusetts, voted to legalize recreational marijuana and another three voted in favor of medicinal pot; voters in California, Washington, and Nevada approved various gun control measures; Californians raised cigarette taxes; and four cities voted to tax sugar-sweetened beverages. Also, Colorado rejected the establishment of a single-payer health insurance system in that state. How are these ballot initiatives changing the public health landscape?

On recreational marijuana, the tide of public opinion is changing the national landscape in spite of bipartisan opposition to this liberalization from elected officials all over the nation. It feels somewhat like the fast-changing tide a few years ago on gay marriage. And it feels unstoppable.

Taxes on sugar-sweetened beverages, at least on the local level, seem to be approaching the level of public acceptance we have seen in prior years with relation to tobacco taxes. The public seems supportive, at least in cities, especially when the revenues raised are clearly defined in terms of spending targets, such as public education. We have yet to see this approach pushed at a state initiative level, which would be a much more challenging proposition.

Regarding the vote against single-payer health insurance in Colorado, it seems that the U.S. sees one of these single-payer ballot initiatives every decade or so, and in each case, they start with some robust public support and then lose in a landslide: California in 1994, 73% to 27% no; Oregon in 2002, 77% to 23% no, and now Colorado in 2016, 80% to 20% no. It has always been a difficult sell and the Colorado results demonstrate that it still is.

Karen Feldscher

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”