I spent the Wednesday after election day in my primary care clinic and found myself incredibly grateful to be immersed in clinical work. Caring for people who are facing tough circumstances like the functional declines of old age, cancer treatment, spinal cord injury, addiction or homelessness reminds me that our work goes on - though now with more urgency and importance than ever. The president-elect and Republican leaders in Congress have vowed to repeal the Affordable Care Act, a law that provides health insurance to 22 million people. In response, Community Catalyst is mobilizing resources to challenge the rollback of the Affordable Care Act and other critical health programs. At the Center, we are particularly focused on ensuring continued access to health care for the most vulnerable, including older adults and individuals with disabilities or serious chronic illness.
As we mobilize to fight the looming threat to coverage for millions of Americans, we are also thinking about how our work to improve health and the delivery of care fits into this chaotic new landscape. Here’s what our Magic 8-Ball has told us so far:
You May Rely On It
Some of the factors pushing improvements in health care will continue. For instance, Medicare drives a large part of federal spending, and there has long been widespread, bipartisan acknowledgment that the current fee-for-service system is expensive, fragmented and failing many of the people it is intended to serve.
The Obama administration, through the Affordable Care Act, accelerated the move to tie payment to quality through initiatives such as Accountable Care Organizations, bundled payments and primary care medical homes. I expect that this shift will continue.
For example, the Medicare Access and CHIP Reauthorization Act (MACRA), which shifted Medicare physician payment into value-based models, was a bipartisan solution for repeated cliffs in physician payments. While some aspects of implementation could change, I do not expect legislative changes to this law. As a result, the template for value-based payments to physicians in Medicare (which tends to strongly influence health care in other sectors) is already set.
Ask Again Later
In other areas, uncertainty dominates. While MACRA is expected to stand, the fate of the Center for Medicare and Medicaid Innovation (CMMI), which was created by the Affordable Care Act to test new payment and delivery models, is uncertain. CMMI is disliked by many Congressional Republicans and the Ryan plan proposed repealing it in 2020. But repealing it poses two complications. First, it was scored by the Congressional Budget Office as budget saving, which means repealing it would add to the deficit. Second, CMMI designed the models that MACRA relies on. While the question of its repeal is uncertain, I expect its authority will be significantly curtailed.
Though it is unclear how efforts at health system transformation will interact with other policy developments, there are several new threats to success. The most pressing and obvious is loss of coverage. Lots of people in Marketplace and expansion populations have serious/chronic illnesses and improving care won’t help these individuals if they lose their coverage. In addition, I am concerned that in the new environment, where funding cuts to Medicaid and other social services are likely, there will not be interest in the investments of time and money needed to make health system transformation successful for those populations who stand to benefit most. And finally, we will need to guard against models of payment that put the consumer at risk through high deductibles or co-pays. We’ve known for decades that cost-sharing has serious consequences for the poorest and sickest among us.
One influential factor to watch is how much private payers will continue to support value-based payment models, and to what degree provider systems have already adjusted the way they deliver care - the health care system is a tanker and if it has already started to turn, its momentum may carry it on its course.
Without a Doubt
Whatever happens, as consumer advocates we must continue our fight for health care policies and practices that achieve better health, particularly for vulnerable populations. Here are four reasons that improving care and engaging consumers in the process at every level is both a moral imperative as well as a movement with ongoing strategic and political importance.
- First, improving care through solutions that advance the triple aim of better care, better health and lower costs give us mechanisms for sustaining public programs in the long run. In contrast to simply slashing benefits or cutting provider rates, these strategies can start to address the structural factors that impact the long-term cost curve. For example, we’ve seen how care coordination can reduce costly and unneeded services and how programs can prevent costly conditions such as diabetes and asthma.
- Second, consumer engagement has resonance across a broad range of models. It’s no accident that consumer engagement and person-centered care have been an important part of both Democratic and Republican strategies, as well as private entities like health plans and provider organizations. This reflects the understanding of the consumer’s central role in the success or failure of health care proposals. This resonance will give us, as consumer advocates, an entry point to define a model of consumer engagement that addresses consumer and community needs.
- Third, our work focuses on vulnerable communities - including older adults and people with disabilities and their caregivers - that are served by a Medicaid program whose future is at risk. It is critically important to empower and organize these consumers to be effective advocates for their health needs, including access to health coverage and a health care system that meets their needs.
- Finally, efforts to improve the delivery of care give us the opportunity to work with a wide range of partners, including payers, providers and community-based organizations. These relationships – including our ability to partner with unconventional bedfellows – will continue to be critical for our success as we face a daunting and challenging new landscape.
I know that in so many ways, our work just got a whole lot more difficult. But there is so much for consumers and consumer advocates to do. Health care was and remains local. We need to work in our own communities, health care organizations and states to ensure access to high-quality, person-centered care: the care that all of us, the consumers we serve, our parents and our children depend on.
While the health care landscape may be changing, our goal remains the same: find a better way to better health. For everyone.