Tuesday, November 29, 2016

Tom Price: Obamacare Slayer

Make no mistake about it, President-elect Trump's appointment of Rep. Tom Price (R-GA) to head the U.S. Department of Health and Human Services (HHS) guarantees sweeping changes to the Affordable Care Act (ACA), aka Obamacare, as we know it.

Lets get one thing straight though...there is no such thing as 'a complete repeal of Obamacare.' That horse has already left the barn. Billions of dollars and thousands of pages of regulation have already been devoted to research that will help revolutionize modern medicine, novel programs that are improving the value of our health care dollar through institutions like the CMMI and PCORI, and necessary health care workforce/infrastructure investments in community clinics and primary care. These programs, and many others in the Affordable Care Act, are actively impacting millions of lives for the better.

What we are talking about now are controversial items like The Individual Mandate, The Medicaid Expansion, The Minimum Benefits Package, and The Income-Based Tax Subsidies. Price has been a vocal opponent of all of these, and has spelled out his alternative in the Empowering Patients First Act. In short, his proposal attempts to loosely preserve the ban on pre-existing condition exclusions (the moral center of Obamacare) combined with more flexibility based on an individual's needs, but exposes many poorer, sicker or older individuals...those who typically need insurance the most...to higher costs in the process. Yes, we need more young and healthy individuals to be insured to balance the 'risk pool'. This is how affordable insurance inherently works. But pricing out the most vulnerable and needy individuals from the system in the process puts an even bigger burden on an already strained safety net and completely defeats the purpose of what we are trying to prevent (read: sick, uninsured individuals who are avoiding insurance premiums, waiting until they are on death's door, then showing up in my ER). An inclusion of a high-risk insurance pool, as proposed in Paul Ryan's A Better Way, could mitigate some of this, but these have proven to be vastly more expensive than anticipated. Moreso, a repeal of the Medicaid Expansion and transition of the program to 'block grants' would effectively strip health insurance away from millions of poor Americans who don't itemize their tax deductions and would see little benefit from the proposed tax credits. See this overview for a good summary of Price's proposal. Finally, a successful removal of the Individual Mandate -but keeping the popular ban on pre-existing conditions- leaves the door open to the dreaded Death Spiral, a dire process universally recognized by health policy analysts.

One concept he supports, though, that is particularly intriguing is the cap on the pre-tax health insurance costs that most Americans employees enjoy. While effectively a tax increase, I have long been a proponent of removing the employer from the equation in order to truly promote competition and hold insurers more accountable to premium increases. If this was included in a broad tax-reform effort (an effort championed by the President-elect), many of the worries of supporters of the ACA could be mitigated with respect to safety-net financing.

Representative Price is shrewd pick, a well-informed physician and a confident speaker. He is an active member of the American Medical Association (AMA), yet much of what he will propose will be in direct opposition to what the AMA, the largest representative group of America's doctors, believes is best for our patients. Below are the core values of what the AMA believes are necessary looking forward, passed just this month. I have highlighted the portions that are under greatest threat.

Looking forward, the following questions for Dr. Price, Mr. Trump, the Republican-led government, and all involved stakeholders are paramount:

- How do we possibly preserve the ban on pre-existing conditions (guaranteed insurance) without a strong mandate that every American must have health insurance?

- Are our elected officials prepared to uproot a program that has already insured tens of millions of individuals, thereby wasting billions of taxpayer dollars already invested in state and federal insurance exchanges?

- If so, are voters prepared to accept repeal next year without a real replacement, cloaked under the guise of  'a two year transition plan'?

-What can legally be repealed under the Budget Reconciliation process, which is immune to the Filibuster and 60-vote requirement in the Senate?

- Will special interests like health insurers, hospitals, and physicians continue to advocate for access to necessary care for the most vulnerable Americans, i.e. the Medicaid expansion?

Tuesday, July 12, 2016

The ACA and Health Care Reform: President Obama does JAMA

This week, the Journal of the American Medical Association (JAMA) published a report entitled Health Care Reform: Progress to Date and Next Steps authored by none other than Barack Obama, JD, the first sitting president to do so in the prestigious medical journal. While he surely had a little help with the piece (68 references!), the single-author, swan-song brings some unique gravity to its contents. Since passage of his legacy the Affordable Care Act (ACA), our health care system has experienced unprecedented change (mostly for better...but some for worse). Cutting through the fluff, here are the some of the major highlights of the paper, with achievements including:

  • Guaranteed preventive care for all, including contraceptive coverage and domestic violence screening and counseling for 55 million women
  • Defined caps on annual out of pocket spending to over 95% of workers in employer-based health insurance plans
  • Tools and research bodies to test new payment models that will reduce waste and improve the value of our health care dollars
  • 20 million more Americans with health insurance, dropping the national uninsured rate to single digits for the first time in history from 16% to 9%:

The President admits that there are plenty of areas where the ACA fell short. While the graph above proves success, insurance coverage does not directly equate to access to care, as many newly insured continue to face barriers in obtaining much needed primary and specialty care. Worse, 19 red states still have not expanded their Medicaid programs, leaving 4 million low-income Americans without affordable coverage options.

He also offers significant policy changes for future consideration to improve the law and help curb the unsustainable growth in national health spending, including:

  • A public insurance option (!) in markets that are dominated by one or two insurers who have stifled competition
  • Improving prescription drug price transparency and granting federal authority to negotiate pricing for high-cost drugs in Medicare and Medicaid

The law survived multiple bouts with the Supreme Court and countless attempts at repeal in the legislature, yet is certainly here to stay. Looking forward in this hyperpartisan era, he urges pragmatism and finding common ground, resisting the many well-funded special interests in our American health care system that put profit over patients. And in a well-placed nod to bipartisanship, he concludes with a quote from former GOP primary candidate Governor John Kasich explaining his decision to expand Medicaid in Ohio:

 “For those that live in the shadows of life, those who are the least among us, I will not accept the fact that the most vulnerable in our state should be ignored. We can help them.”

Saturday, August 9, 2014

Proposition 46: Vote 'No' on the California MICRA Ballot Measure this November

Here is the first of many educational videos explaining why it is important for California voters to vote NO on Proposition 46 this November. This deceptive ballot initiative is a hodgepodge of new regulations that would cost taxpayers millions and force many community clinics to close their doors due to increased health care costs. This measure couldn't come at a worse time as we are trying to increase access to health care services for the millions of newly insured Californians. 

That is why hundreds of groups already oppose this proposition, including Planned Parenthood, the ACLU and SEIU, the California Chamber of Commerce, the California Teacher Association, dozens of clinic and hospital associations, the California State Firefighters Association, and many more. Join the coalition, and learn more about the initiative here: No On 46