Health Reform After the ACA: What’s Next for CFHA’s Four Ps: Practice, Programs, Policy, and Partnerships

• Len M. Nichols, Ph.D.

• Director of Center for Health Policy Research and Ethics

• Professor of Health Policy

• George Mason University

• Fairfax, VA 22030

Session # Opening Plenary

CFHA 19th Annual ConferenceOctober 19-21, 2017 • Houston, Texas

Faculty DisclosureThe presenter of this session has NOT had any relevant

financial relationships during the past 12 months.

Conference Resources

Slides and handouts shared in advance by our Conference Presenters are available on the CFHA website at http://www.cfha.net/?page=Resources_2017

Slides and handouts are also available on the mobile app.

Learning Objectives

At the conclusion of this session, the participant will be able to:

• List Challenges and Opportunities in federal, state, and local policy environments re: coverage, payment, and integrated care

• Identify key decision points and choices faced by policy makers and stakeholders alike

• Discuss options for clinicians and organizations given the environment and policy choices

1. All pictures were copied from google images or news sites

2. All data sources/research references are on each slide

3. All other ideas came from my little mind

Bibliography / Reference

Learning Assessment

A learning assessment is required for CE credit.

A question and answer period will be conducted

at the end of this presentation.

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Overview

• State of ACA Debate (as of This Morning!)

• How policy choices could impact integrated care

• A pro-active agenda for the near term and long term

• Q&A

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Effects of ACA

• Coverage

• Cost

• Quality

• Health

• Politics

• Future

0

5

10

15

20

25

2010 2011 2012 2013 2104 2015

Potentially Preventable Readmission Rates, Medicare

all conditions AMI HF Pneumonia COPD

Source: MEDPAC, March 2017, Annual Report to Congress

Exhibit 7. Change in Rates for Hospital-Acquired Conditions, 2010–13

-19%

-28%

-49%

-8%

-20% -19%

-3%

-18% -17%

-60%

-50%

-40%

-30%

-20%

-10%

0%

Source: Agency for Healthcare Research and Quality, Efforts to Improve Patient Safety Result in 1.3 Million Fewer Patient Harms: Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted from 2010 to 2013, Dec. 2014.

Sommers et al

Annals of Internal Medicine

160(9)

Sommers et al

16

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Philosophy of ACA vs. NOT ACA

• ALL vs. Some

• Rules vs. Liberty

• Population health vs. personal health choices

• Compensating for disadvantages vs. reducing tax burden

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What We All Agree Upon Now

• Health Care and Health Insurance Cost Too Much• ACA is a “disaster” (Except for the parts people like)• “Fixing” the ACA is complicated

➢ 20m+ gained coverage, most like/need it; ACA more popular than ever

➢ Most of coverage gains in Medicaid➢ Many insurers pulled or threatened to pull out of

marketplaces➢ 3-4m hurt by benefit mandates and risk pooling*

• Governing is harder than campaigning

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What We All Agree Upon Now

• Health Care and Health Insurance Cost Too Much• ACA is a “disaster” (Except for the parts people like)• “Fixing” the ACA is complicated

➢ 20m+ gained coverage, most like/need it; ACA more popular than ever (as is Single Payer)

➢ Most of coverage gains in Medicaid➢ Many insurers pulled or threatened to pull out of

marketplaces➢ 3-4m hurt by benefit mandates and risk pooling*

• Governing is harder than campaigning

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Why Replace/Repair/Renew discussion has taken so long

• Even with goals agreed upon, health reform policy is HARD

• Different views of goals within Republican elected officials

➢ Build the BEST, a beautiful system, cheaper and better for all➢ Get government out of health care, reduce taxes➢ Reverse new entitlements (Medicaid + Marketplaces)➢ Provide freedom, not guarantees➢ Set Medicare and Medicaid on fixed-growth rate futures➢ Inject freedoms but preserve coverage to avoid risk of political

backlash (note: requires keeping tax money + Medicare cuts)

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Creating Uncertainty and Sabotage

• EO to “create” Association Health Plans

• Notice of ending Cost Sharing Reduction Payments

• Cuts in outreach and enrollment funding for federal marketplaces

• Denial of OK and modification of MN waivers

• Bi-partisan efforts at stabilization underway➢ Problem Solvers in the House➢ HELP Committee in the Senate, Finance members➢ Governors Kasich (R-OH) and Hickenlooper (D-CO)

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How would changes to ACA Affect CFHA Agenda of Integrated Care?

• Retreat from coverage expansion would constrain Medicaid programs➢ Likely to reduce expansive private benefits as well

• There is some good news attendant to ACA implementation:➢ Readmission penalties taught hospitals about SDOH➢ Opioid crisis + criminal justice has made law

enforcement allies of coverage expansion and treatment

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Fall Calendar Crowded

• Budget Reconciliation option for ACA Repeal and Replace expired Sept. 30➢ New Ones focused on tax policy ($1.5T PIT cut), but include room for Medicaid

(-$1T) and Medicare (-$480B, plus premium support) spending growth cuts, also another $1T of corporate tax cuts (note: S&L tax deduction ended in House budget),

• CHIP reauthorization➢ Sens. Hatch and Wyden (Finance) have agreed on contours of 5 year deal, with

enhanced match for two years, phased out by 2021➢ House E&C CHIP proposed language mirrors Senate Finance as of 10/3

• ACA “fix” deal emerging in Senate HELP Committee, Schumer would like to tie CHIP to “fix” legislation (and Trump calls “Chuck”from time to time…?)

• Clock is ticking in states with CHIP funding deadlines looming (AZ, CA, CT, HI, ID, MS, NV, OR, PA and UT say they’ll be out of funds before 12/31/17)

• FQHC funding also expired Sept. 30th; Trump wants his Wall as price of DACA

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Where Are We Headed?

• Attempt to repeal and replace will not end soon ➢ Rs need Medicaid money for the tax cut they want to enact

• SCHIP will be re-authorized, probably by Thanksgiving

• Tax reform/cut debate will intensify pressure to reduce federal health care spending

• States are going to get more discretion, maybe/probably with less federal money

• We’re going to decide what kind of country we are, or want to be

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Some Final Facts to Ponder

• Family premium / median family income = 24%

• Family premium / annual minimum wage = 115%

• Federal Debt held by public / GDP = 77%

• US taxes 8% of GDP LESS than OECD Average

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A Shared Agenda with Utopian Economists?

SDOH

Health Use

Employment

Cost

Investment in Reducing SDOH Deficits

1

3

4

GOVT.

Margin/Profit

6

7

9

SUSTAINING INVESTMENTS IN SDOH DEFICITS

11

11

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Technical Problems and Solutions

• Failure of imagination/conceptualization

• “investing” in SDOH deficits, like BH capacity, is undersupplied just like quasi-public goods

• Free riders due to non-exclusive and non-rivalrous nature

• There are technical solutions (Clarke-Ledyard, dynamic learning games) but they require trust

• Trust = f (credible source for data and shared experiences)

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What We Need

• Better Elected Leaders

• Local roundtables to create and share data and experiences around integrated care and SDOH

• Payment reform models that include truly integrated care➢ Respond to CMMI RFI➢ Consider submitting models to PTAC

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