Immigration and the nuclear deal with Iran dominated the first Republican presidential debate last night. Health care issues were decidedly second tier with candidates saying expected things about defunding Planned Parenthood and repealing the ACA. The Fox News moderators pushed the candidates unexpectedly hard in some instances, but no one was pressed on "replace." Although Donald Trump has been ridiculed for saying he would replace the ACA with "something terrific," there is not much difference between him and the rest of the candidates or Congressional leaders on that score.
The problem, as Paul Krugman pointed out a couple of days ago, is that the ACA is Republican health reform in its essential features (competitive private insurance markets, tax credits and personal responsibility). Sure, candidates could propose tweaks, like changing the current personal responsibility provisions from a tax penalty to a late enrollment fee (as does Medicare Part D), but such modest changes hardly justify the venomous attacks against the ACA. The growing problem for the candidates is repeal rhetoric is increasingly discordant to the country as a whole while retaining strong appeal to the most likely Republican primary voters and activists.
One thing that was neither asked nor volunteered was how candidates would help families with high and persistent health care costs. The ACA has been a big step forward and a lifesaver for many. However, for those with expensive chronic conditions, cost-sharing still can be a heavy burden. That's one issue we would like to see candidates from both parties address during this campaign.
Speaking of No News
For those who need it, Margot Sanger-Katz has a useful review of why expanding coverage and access to clinical prevention don't save money. The "hook" for the story was the recent Centers for Medicare and Medicaid Services (CMS) Actuary's report on health spending, but there was nothing new there. The only thing I would add to Sanger-Katz's overview is the connection of coverage expansion and cost savings is somewhat clouded by the fact that all industrial countries with universal coverage systems spend less than the U.S. This is primarily because they bargain for much better prices for health care goods and services than the U.S., and they have greater administrative efficiency and more rational organization of care. The ACA has taken steps (Minimum Medical Loss Ratio, rate review, ACOs) to bring some of those features into the U.S. health care system, but we still have a long way to go.
Arguably, the lower spending of health systems in other countries is also due to the fact those countries invest more in improving the social determinants of health (housing, income support, social services along with a less punitive approach to criminal justice) thereby reducing the need for a lot of health spending.
Can We Improve the Quality of Quality Measurement?
The Commonwealth Fund and Kaiser Family Foundation are out with a new survey that shows most primary care physicians think both physician quality measurement and CMS's hospital readmissions penalties are having a negative effect on quality. While it would be tempting to respond cynically that this simply reflects the desire of the delivery system to escape accountability, there are good reasons to take these concerns seriously.
Although quality measurement lies at the very heart of efforts to move our health care system from one that rewards volume to one that rewards value, our current approach to quality measurement is cumbersome, confusing and perhaps focused on the wrong things (as outlined not too long ago by the Institute of Medicine).
As for the readmissions penalty program, CMS seem reluctant to adjust the program despite some fairly obvious glaring flaws, most notably the fact that hospitals with identical performance but different demographics will face different penalties (i.e. hospitals that care for more poor people will have higher penalties even if their outcomes for poor patients are just as good as facilities with a more affluent patient mix).
Concern is growing within Congress, however, and it is possible that both quality measurement and the readmissions penalty program will be addressed in bipartisan legislation later this year.