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?


  1. The thing is that these are genuinely bad ideas. High risk pools? Point of service shopping? Across state lines purchase (code for junk insurance)? It's difficult to know what to do here because although a number of the R proposals could augment and improve the system they necessitate the ACA framework.

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