What's at stake in a repeal of the ACA? Some things you may not have thought of...

The focus of Affordable Care Act is insurance coverage and that's what has been reported about most since the law was passed.  But there's much more to the 900 plus pages of the ACA.  It also includes many provisions that most people don't associate with "Obamacare."

Here is a list, in no particular order, of some of the provisions not directly related to insurance coverage that are at risk if the ACA is repealed:

• Closing the Medicare prescription drug donut hole.
• Calorie counts and nutrition information on chain restaurant menus.
• Privacy rooms and break time at work for nursing mothers.
• Community needs assessments by non-profit hospitals to justify their tax exemptions.
• Online posting of non-profit hospitals' financial assistance policies.
• Ability for women to choose their Ob-Gyn without a referral from another primary care physician.
• The actual cost of insurance coverage appears on large employer W-2 forms.
• Grants to communities to promote healthy lifestyles.
• Grants to small businesses to create workplace wellness programs.
• Grants to states, communities, and nonprofits for disease prevention and health education.
• Expansion of school-based health centers and community clinics.
• Increased rebates to states from pharmaceutical manufacturers.
• Demonstrations and other programs to reduce health care costs, improve quality and delivery of services, and enhance value of care.
• Prohibits rescission, the practice of dropping a patient from insurance coverage when they get sick.
• Programs to detect and deter fraud in Medicare.
• Increased the deduction for qualifying medical expenses from 7.5% to 10% of adjusted gross income for taxpayers under age 65.
• Simplified and streamlined the income determination process for Medicaid eligibility.
• Expanded Medicaid eligibility for foster kids.
• Simplified insurance company explanation of benefits forms and outlawed small print (all print must be at least 12-point font).
• Open reporting by pharmaceutical companies and medical device manufacturers of gifts and other payments to physicians to promote their products.

Many reports, blogs, and other analyses are being written about the direct impact that repeal of the ACA may have on insurance coverage (I may write about that myself).  Popular provisions like prohibiting insurers from denying coverage to those with pre-existing conditions and allowing dependents up to age 26 to remain on parents' insurance policies are at risk.

But much more is at risk, as well.  The ACA has contributed to making the health care system more affordable, more humane, and more transparent.  We shouldn't go backwards on these provisions.

Can a Three-Legged Stool Stand on One Leg?

As Republicans in Congress twist themselves into knots over what to do about the Affordable Care Act (ACA), I thought it would be useful to go back to basics about the pillars of the law.  Contrary to the mythology perpetuated by many ACA opponents, it's not just a slapdash collection of requirements designed to boost government authority and crush individual freedom.  It actually was constructed in a logical fashion that addresses the reality of how insurance works.

Meet the proverbial "three legged stool."

The first leg is based on one of the most popular provisions of the law, one that even ACA critics have pledged to retain:  the prohibition against denying coverage or charging more to those with pre-existing conditions.  In insurance jargon this is known as "guaranteed issue."

Before the ACA, companies that provided insurance in the non-group (i.e., non-employer) market were free to pick and choose their customers.  Consumers who were considered high risk and likely to incur substantial costs (or sometimes not so substantial) could be denied coverage or charged more.  Sometimes they would be offered insurance that excluded coverage of their condition.  Illnesses that could block someone from coverage ranged from the serious (e.g., cancer or heart disease) to the commonplace (e.g., acne or asthma).

The ACA's prohibition on discrimination against the sick appeals to people's sense of fairness.  But it puts insurance companies at great risk.  If an insurer must sell a plan to anyone who applies, what's to stop a consumer from waiting to get sick or injured before buying a policy?  Companies that sell homeowners insurance can't survive if they allow customers to buy policies while their houses are on fire.  Likewise, health insurers can't afford to sell policies to people who buy them from the back of an ambulance. 

So, the second leg of the stool is a mechanism to compel people to buy insurance while they're healthy.  In the case of the ACA, it's the individual mandate.  It means that with some exceptions, everyone must buy a health insurance policy or pay a fine.

The mandate is the least popular part of the law.  Opponents point to it as the provision that most represents government overreach and an attack on personal freedom.  Nobody likes the government telling them what to do.  But if we want guaranteed issue, we must have healthy people in the insurance risk pool.  So the ACA includes a mandate.

But the mandate creates another problem. Health care is expensive, so health insurance is expensive.  The mandate requires that nearly everyone purchase a product that very few people can afford.

So, we have the third leg of the stool:  financial assistance, in the form of tax credits and subsidies, to help people buy insurance.  This financial assistance requires hundreds of millions of federal dollars and is the primary reason for the high cost of the ACA.  As a result, it too is unpopular with the public.

Faced with a law that includes both popular and unpopular provisions, President-elect Trump and many in Congress have promised to keep the good parts and get rid of the rest.  But that would leave the three-legged stool with only one leg.  And even ACA opponents know that such a stool is a couple of legs short.

As a result, every policy proposal that includes guaranteed issue, including those floated by Congressional Republicans, also includes a form of mandate and some level of financial assistance (I'll write about the details of these proposals in a future post).  They may not be Obamacare, but they're Obamacare-lite.

Because you can't repeal reality.

Can't Anybody Here Play This Game?

The State of the State is ignorant and uninformed (and seemingly proud of it).

Kansas Governor Sam Brownback gave his State of the State address tonight.  It was filled with the usual platitudes about how well things are going here in Kansas (some might have called them delusions).  But what caught my attention was the unforced error that demonstrated just how empty Brownback's rhetoric is and how uninformed this administration is about health policy.

Brownback went through the de rigueur criticisms of the Affordable Care Act (or, more accurately "Obamacare;"  Brownback would never use the actual name of the law).  He patted himself on the back for defying the law and resisting the expansion of the Medicaid program that would cover 150,000 Kansans.  And he demonstrated that he knows very little about the law other than how to repeat inaccurate talking points.

Gov. Brownback derided Obamacare by pointing out the failure of most of the 23 state health insurance exchanges established under the law.  The problem is that there have never been 23 state exchanges.  In his ignorance, he (or his speechwriters) confused state insurance exchanges with CO-OP insurance plans.  While it's true that most of the CO-OPs have failed, these start-up insurance plans are very different animals than the state insurance exchanges (or marketplaces) established under the ACA.

This confusion has been showing up in talking points of ACA opponents for several months.  That Brownback would simply repeat this blunder, and that nobody on his staff, including Lt. Governor Colyer, a physician and the administration's presumed health policy expert, caught and corrected the mistake should tell you all you need to know.

This is a Governor and an administration that simply doesn't understand health policy and doesn't seem to care.  They're adamantly opposed to the ACA, but they clearly know very little about it.

In 1962, manager Casey Stengel responded to the New York Mets historic ineptitude by asking "Can't anybody here play this game?"  The same can be asked of the Brownback administration's knowledge of health policy and the ACA.

Rural Kansas Needs More Physicians. Who's Going to Pay Them?

Kansas Governor Sam Brownback and Lieutenant Governor Jeff Colyer today announced two new programs to bring more doctors to rural Kansas.  As in most rural states, the vast majority of Kansas counties are considered medically underserved, with shortages of doctors, dentists, and other health professionals.

Brownback and Colyer proposed the development of a school of osteopathic medicine in Kansas and a new rural medical residency program.  Both are admirable goals that could help to produce more physicians who will practice in rural Kansas communities.

But training more doctors is only part of the solution.  These doctors also need to be supported after they complete their training and begin to practice.  And here, Brownback and Colyer had little to offer.

The ideas for the osteopathic school and the residency program came from the Lt. Governor's Rural Health Task Force, which met over the course of the last year to assess rural health in Kansas and develop solutions to the workforce shortages, underfinancing, and other problems that have plagued rural areas for decades.  The back story, however, is that the task force was established so the administration could show it was doing something about rural health as it resisted an obvious answer - expansion of KanCare, the state's Medicaid program. 

Accepting federal funding to expand KanCare would bring hundreds of millions of new health care dollars to rural Kansas to cover the uninsured, and at the same time support struggling local hospitals and other providers and create thousands of new jobs (many for all these new physicians).  All discussions of KanCare expansion, however, were shut down by Lt. Gov. Colyer during meetings of the task force.  We don't want Obamacare here in Kansas.

So the question remains.  How are these new rural Kansas physicians going to be paid?  Workforce follows financing, not the other way around (i.e., if the money is there, the doctors will follow).  Is a young physician interested in rural practice likely to locate in Kansas, where many of her patients are uninsured and will not be able to pay for services, or look next door to Colorado, which has expanded it's Medicaid program?

Enhanced workforce, innovative delivery models, and other common solutions to rural health problems are great, but they only go so far.  At the end of the day, we also need money to pay for these programs.  It's right in front of us.  But Gov. Brownback and Lt. Gov. Colyer refuse to see it.

What kind of health plan do voters want?

An illuminating column in the New York Times this morning shows the dilemma facing legislators intent to repeal and replace the Affordable Care Act.  Drew Altman, CEO of the Kaiser Family Foundation, reported the findings of focus groups of working class Trump voters in Rust Belt states.  All of the participants receive insurance via the ACA, either through private coverage in the marketplace or Medicaid.  There was much dissatisfaction.

The focus group participants were concerned about rising premiums, deductibles, copays, and drug costs.  They thought their policies were too complex and didn't like the idea of shopping around and possibly changing plans every year.  They weren't happy with surprise bills for services they thought were covered.  And those with private insurance resented the better deal they perceived those with Medicaid were getting.

In short, they sounded a lot like health insurance consumers before the ACA.  

When presented with possible "solutions" that have been proposed in GOP replacement plans for the ACA, however, they weren't any happier. Catastrophic coverage with even higher deductibles than they face now were labeled as "not insurance at all."  They did not understand heath savings accounts and were skeptical of the concept.  They were fearful of what would happen if there was a gap between repeal of the law and replacement. 

What do they want?  Low out-of-pocket costs, low drug prices, robust provider networks, no surprise bills, and easy to understand policies.  Again, the same things that everybody wanted before the ACA. 

The problem, of course, is that it's easy for politicians to promise unicorns and rainbows.  In the last six  years, the U.S. House of Representatives voted more than 60 times to repeal the ACA.  During the campaign, President-elect Trump pledged to repeal it and replace it with something "terrific" shortly after taking office.  These promises were easy because they weren't yet real. 

But now that repeal could happen, the spotlight is on replacement.  And not a single politician who has screamed for repeal all these years has any idea how to deliver what the focus group voters say they want.  Because it can't be delivered.

Real policy requires tradeoffs.  You want low out-of-pocket costs?  That means higher premiums.  Broad provider networks?  Again, higher costs.  A smooth transition without a gap between plans?  That could take years. 

Will politicians have the courage to be straight with their constituents and tell them these truths?  Until they do, the comments from the focus groups won't change, whether they're made up of Trump voters, Clinton voters, or anybody else.  Regular people aren't policy wonks.  They rely on their leaders to explain to them how this all works.  Will anybody step up?

Welcome and thanks for reading

This blog is focused on health policy issues in Kansas and across the nation.  As we enter 2017, the health system faces extensive change and upheaval.  The new President and Republican majorities in the U.S. House and Senate have pledged to repeal the Affordable Care Act, which has shaped the direction of the health system since it was passed in 2010.  What comes next is anybody's guess.

For better or worse, government plays a key role in the health care system.  How and whether Kansans are able to access and receive health care services will be determined, in part, by decisions made in Washington, DC and Topeka.  The future of Medicare and Medicaid (KanCare in Kansas), as well as the ACA, are all at stake.  These issues will affect every resident of the state of Kansas.

I've spent my 30 year professional career in the public, private, and nonprofit sectors working to ensure the delivery of health services, primarily in rural and underserved areas.  In this blog, I'll do my best to translate what's happening in Washington and Topeka and help you understand how it may impact you and your community.  We all have a stake in the health system; eventually everyone gets sick or injured and needs care.  I hope to empower my readers with a deeper understanding of the issues that have engaged me for all these years.

Expect a lot of policy analysis and news, mixed with informed opinion, and probably more than occasional outrage.  And hopefully a little humor every now and then.

Thanks for reading.