One curious feature of our current moment in health policy is how divergent the impending course of action pledged by Republicans in Congress and the incoming Trump administration is from the preferences of major health care industry stakeholders. Dominant models of public policy making assume that the preferences of large economic stakeholders in a given policy area will exert a lot of sway over the outcome. To be sure, every interest group has something(s) they want to change about the Affordable Care Act (ACA), but there is very little appetite among providers, hospitals or insurers for rolling back coverage. For example, a recent survey in Modern Healthcare found overwhelming opposition from health care CEOs to repealing in the ACA without a replacement at the ready. Yet that is the course the Congressional Republicans seem ready to embark on – inflicting serious pain in the process, especially on providers (not to mention the millions of Americans who stand to lose coverage).

It seems hard to imagine a parallel in any other industry. (Of course, the banking industry didn't exactly love the Dodd-Frank bill, but its passage was only made possible by the self-inflicted meltdown of the industry). The present situation is so unusual that it demands an explanation. I don't presume to be able to peer into the minds of the repealers, but I think there is some combination of three things going on:

  1. Ideological extremism. An anti-government ideology is so profoundly held within most of the Republican leadership in Congress today that pursuing fervently desired goals is totally unmoored from considering any real-world consequences. Thus, the ACA must be repealed “because-government.” The real-world harms – the rise in medical debt and personal bankruptcy, the erosion of hospital finances, the increases in mortality – are just not germane.
  2. Health care as "piggybank." The money for touted big tax cuts for the wealthy and increased military spending has to come from somewhere. With federal discretionary spending already pared to the bone, there just isn't another major source of money beside the health realm to tap in order to pay for these "more important" priorities.
  3. “The dog catches the car” problem. For years, Congressional Republicans have been able to score political points railing against the ACA and passing veto-certain repeal measures without having to deal with the pesky problem of figuring out what would come after. The election of Donald Trump caught pretty much everyone by surprise, but it is far too late now to moderate the rhetoric. Repeal has been repeatedly promised and now, with control of both houses and the presidency, come January, the promise must be fulfilled regardless of the problems it might cause. There is no room for backtracking.
 

Are Republicans Serious About "Replace"? We'll Find Out Soon

To be fair, there are some real ideas out there on the Republican side about how to replace some provisions of the ACA. For example, various policy makers and conservative academics have proposed a variety of alternatives to the individual responsibility requirement, including continuous coverage, auto-enrollment and late enrollment penalty. Different ways to design financial assistance and minimum coverage are also possible (not to say that these alternatives would work better than the ACA). The problem is how these ideas interact with the "piggybank" scenario (see #2, above). Any serious alternative requires money. If the first thing the new Congressional leadership and incoming president do is pull a ton of money out of the system, it will be an early sign they are not serious about health policy and that repeal is just a stalking horse for transferring wealth up the income scale.
 

Now Is the Time to Speak Up!

It cannot be overemphasized that the threat to create chaos in health care for millions of Americans extends far beyond proposals to roll back the coverage gains made by the ACA. Enormous cuts to Medicaid are also on the table. Even Medicare is not safe, a fact underscored by the recent comments of Representative Tom Price, thought to be a leading contender for the top job at Health and Human Services under a Trump administration, who confirmed that the efforts to overhaul (aka cut) Medicare would begin in 2017. It is fair to say that there is no electoral mandate for these cuts to Medicaid and Medicare, but the American people may very soon find these programs at risk, nonetheless.

The takeaway is that while the ACA may be first on the chopping block, Medicaid and Medicare will follow closely behind unless we mobilize now to save these vital programs. Members of Congress are saying they aren't hearing from people complaining about repeal, so it’s crucial for all of us to raise our voices loudly right now.

The nationwide shift in the way we view and respond to problematic use of drugs and alcohol got a big boost last week with the release of Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. The report affirms and highlights what many advocates, researchers and providers in the field have been promoting for years: addiction is a health issue, not the result of any individual’s moral shortcomings, and must be addressed through a public health approach. This means shifting the focus away from punitive policies toward a comprehensive strategy that combines health and social services. This report provides new impetus for us to act collaboratively to address substance use disorders.

In the 1960s, the Surgeon General’s report on smoking contributed to a cultural shift by connecting smoking and cancer. Through facts and science, the report helped Americans understand this causal relationship. This shift eventually led to policy changes and regulations that reduced smoking and related diseases.  Facing Addiction, the first Surgeon General’s report on the topic, has the potential to create a similar cultural shift by legitimizing addiction as a public health issue and proposing action priorities. Now it’s up to advocates, their allies and policymakers to lead the way forward.

Crucial to this work is the understanding that there is no one set path to wellness for individuals who experience problematic use of alcohol and drugs. Providers must work with individuals to determine what combination of factors within and beyond the health system will enable successful management of an addiction. The report calls for prevention, treatment and long-term support approaches similar to the way the health system handles management of other chronic illnesses. It synthesizes the evidence that these methods work for substance use disorders. It also reaffirms the critical importance of protecting comprehensive health insurance coverage, and the improvements made through the Affordable Care Act.  

The report lays out some strategies for change that align with our vision here at Community Catalyst including:

  • Prevention: The report promotes SBIRT (Screening, Brief Intervention, and Referral to Treatment) and other prevention strategies starting in adolescence when most addiction begins. Our SBIRT project helps support an upstream approach to substance use disorders that is crucially needed, yet often underused and underfunded.

  • Treatment: The report emphasizes that treatment should be person-centered and include strengths-based approaches. The key component is working with the individual to determine a treatment plan, incorporating a variety of services that includes medication-assisted treatment, behavioral therapies and recovery support services. The most effective treatment, according to the report, “attends to multiple needs of the individual, not just his or her drug abuse.”

  • Integration: The report highlights evidence showing effective management of substance use disorders integrates medical treatment for addiction with a broad range of health and social services including housing and employment support, and child welfare. This efficient approach is beneficial for both the individual and society. The report showcases how Medicaid has been particularly groundbreaking in its approach to substance use disorders, encouraging states to conduct demonstrations to test policy innovations through 1115 waivers, and provide care coordination through Health Homes. At Community Catalyst, we advocate for this whole-person approach, recognizing that integration of social and community supports with health services is essential to promoting overall health.

  • Harm reduction & alternatives to incarceration: The report underscores the need for programs that “work with populations who may not be ready to stop substance use – offering individuals strategies to reduce risks while still using substances.” This approach to substance use is crucial to Community Catalyst’s work on pre-arrest diversion, which seeks to divert people away from the criminal justice system (including arrest and jail) and into health and social services.

  • Recovery support services: Because recovery-oriented services are designed to draw on the person’s goals, strengths, family supports and community resources, they have the potential to be more responsive to the cultural diversity of the communities they serve – a big priority of ours with regard to health equity and reducing health disparities. The report affirms the need to enhance recovery services. We are proud to be participating in SAMHSA’s Bringing Recovery Supports to Scale Technical Assistance Center Strategy (BRSS TACS).

This report is an important tool for all those working to advance policies and practices that improve the health of people with substance use disorders. It arms us with evidence and effective strategies. It also lays out the need for community leaders across health, government, social services, education, law enforcement, business, faith, academic and advocacy sectors to work together.

We strongly urge the next administration to use this report as a blueprint as they develop their plans to address addiction. Although it is tragically unfortunate to be in the midst of a national addiction crisis, we have the attention of the nation and the highest levels of government. It’s our responsibility to act and to advocate for others to join together to forge effective public health-focused solutions.

 

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.

How the voters thought about health care

The election is over and Donald Trump, to the surprise of most people (including, apparently, the Trump campaign team) will be the next president of the United States. Although this will have profound consequences for health policy, it does not appear that health care issues were a major factor in determining the outcome.

Certainly, health reform never became the political plus that proponents hoped it would be, but neither was it the albatross that critics claim it was. Opinions about the health care law have remained essentially stable and dominated by party identity since the Affordable Care Act (ACA) was passed. In addition, health care remained a second-tier issue throughout the campaign.

According to analysis by Robert Blendon at the T. H. Chan Harvard School of Public Health, a single core question – whether you believe the federal government should play a significant role in ensuring that people have access to coverage – was strongly associated with both your attitude toward the ACA and toward the presidential candidates. People remain largely uninformed about the details of the ACA. Their attitudes are driven by values, not the specific provisions of the law (many of which remain broadly popular).

One interesting correlation between health and voting was discovered by staff at The Economist. Counties with high rates of obesity, diabetes and heavy drinking and low rates of physical activity went heavily for Donald Trump. These voters, hit hard by deindustrialization and not benefiting from a rebounding economy, made up a small percentage of Trump voters. But they may have provided him with his margin of victory in key battleground states.

Turning from the electorate to policy that may flow from the outcome, the Affordable Care Act is a law that has had nine lives. But in the wake of Trump's victory it is now threatened like never before. Truly, the fate of the ACA per se is neither here nor there. The urgent question that confronts us now is how to preserve the coverage gains and financial protections that millions of people now enjoy. Twenty-two million people could lose their coverage outright if the ACA is repealed, but that is just the tip of the iceberg.

The ACA provides important benefits to millions of people who never even glanced at Healthcare.gov, such as protections against pre-existing condition exclusions and charging sick people more for their coverage, limits on rates charged to older adults, the bans on lifetime benefit caps and charging women more than men, and better access to preventive health services. All of these protections are at risk if the ACA is unraveled.

And the damage doesn't stop there. House Republicans have put forward the outline of a plan that would undermine coverage for millions of children, seniors and people with disabilities who depend on Medicaid. They have also proposed reducing benefits and increasing costs for Medicare beneficiaries.

 

Would you buy a used car from these men (sight unseen)?

For six years, Republicans have been talking about repeal and replace, but they have yet to coalesce around a replacement plan. Now Republican leaders in the House and Senate are pursuing a strategy of repeal now and replace later. They are proposing to light a fuse by repealing essential components of the ACA but delaying the effective date. Essentially, they’re saying, "Trust us we'll come up with something good to replace it before the bomb goes off."

But there is nothing in the past six years that should give people any confidence that Republicans can pull it off. A large cohort of Republican voters (and presumably their representatives) would be content to repeal the ACA and replace it with nothing. In addition, the overall intent of the Ryan blueprint, much of which is also reflected in Trump's policy agenda, seems to be to use health care programs as a piggybank to pay for (wait for it) tax cuts for the wealthy and increased military spending.

There is also a great likelihood that the "bomb" will go off early. Even if there is a delay in cutting funding for premium tax credits, insurers are less likely to participate. And the more uncertainty there is about the shape of any future system, the less likely healthy people are to sign up for coverage. This will drive premiums up and enrollment down.

 

Meet the real Donald Trump

President-elect Trump's position on these issues is unclear. During the campaign, Trump said a lot about protecting Medicare (and Medicaid). While he was clear about repealing the ACA, he often spoke about making sure people had better, more affordable coverage. Cynics might think that he was about as sincere as a snake oil salesman promising miracle cures. Certainly his recent embrace of "Medicaid flexibility" and Medicare modernization," both often code words for program cuts, is cause for concern. An early tip off as to his true intent will come as he positions himself relative to Congressional plans to repeal without having a replacement plan ready.

Once funding for premium tax credits and Medicaid expansion is repealed, it is no longer available to help finance a replacement plan. This means that whatever comes next will be much stingier than would be the case were that funding still available. Reduced funding will not only undermine coverage for the newly insured, it will also financially destabilize many providers and result in a large cost-shift to state government.

However, it appears that the incoming Trump administration is on board with the Congressional scheme making his promises to protect Medicare and Medicaid and replace the ACA with "something terrific" much harder to realize. Because separating repeal from replace would be so damaging, it is important to mobilize now against this approach. Republican leaders are hoping to hold a repeal vote in January in order to present a repeal bill on or near Trump's first day in office. Much of the health care community, including Community Catalyst, is now focused on opposing this plan to repeal the ACA without a replacement.

 

We the People

Donald Trump was elected by a minority of the electorate. Most people do not want to see the ACA repealed. They don't want to go back to the days when insurance companies could discriminate against people based on their health status. They don't want to cut health benefits for children, seniors, or people with disabilities. The challenge now is to ensure that the views of the minority do not undermine hard-won health security for millions of Americans.

With the musical “Hamilton” putting the American Revolution into popular consciousness, a couple of random bits of Revolutionary War trivia have recently popped into my mind. As the reality of Trump's upset victory sank in, I recalled the song that the British played as they surrendered to Washington at Yorktown—“The World Turned Upside Down.” But now, as the shock has worn off, I recall instead the words of John Paul Jones (the Naval hero, not the Led Zeppelin bass player): “I (we) have not yet begun to fight.”

73 million.

73 million. This is the number of people who rely on Medicaid for their health coverage - and almost half of them are children. It’s the number that stands out on the screen as we read Kaiser Health News’s assessment of how a shift in Medicaid policy would impact consumers. As we near the end of one administration and ready for a new one, it is important to reflect on the reach of Medicaid and the Children’s Health Insurance Program (CHIP) and their impact and role as a lifeline for families to access needed health care.

And while uncertainty may surround what the next administration might do, one thing is certain: Medicaid and CHIP work.

My Medicaid Matters

Medicaid and CHIP are the cornerstones of coverage for low-income families.

Medicaid is a multi-generational program set up to protect our most vulnerable consumers at any stage in their lives. Under the ACA, Medicaid has expanded in many states to cover people in the coverage gap – those earning too much for traditional Medicaid but too little to qualify for tax credits in the Marketplace. Alongside Medicaid, CHIP has provided coverage to the almost eight million children whose families currently or once lived in this gap.

Healthy families lead productive lives: healthy parents contribute to their workplace and their community and healthy children come to school ready to learn.

Medicaid and CHIP work to increase access to timely and needed care. Studies show that children who have access to continuous health services lead healthier, more productive lives over the long term. We know that restricting access to these vital programs harms children and their families and can limit their opportunity to lead healthy lives.

Medicaid and CHIP play an important role in advancing health equity for children.

According to the Kaiser Family Foundation, Medicaid and CHIP cover more than half of all Hispanic children (52 percent) and Black children (56 percent) compared to a little over a quarter of white (26 percent) and Asian children (25 percent). As the Kaiser report shows, Medicaid and CHIP, in partnership with the ACA, are important initiatives to reduce health disparities and increase access for children of color. Coverage is the first step in securing better health outcomes for all children. And for children from racially and ethnically diverse backgrounds, Medicaid and CHIP open a door to needed health services.

Let’s start collecting and sharing the stories of the low-income families that have benefited from Medicaid and CHIP.

More than 73 million. That is how many stories are out there about the success of Medicaid and CHIP. Let’s get started on collecting those stories, like advocates in Pennsylvania have done through their new InsurePA website, so we can ensure that Medicaid and CHIP will continue to support children and families for years to come. Stay tuned for helpful messages and other tools from Community Catalyst to assist in your story collection efforts.