Category: Unsustainable Fiscal Path

In Part 1 of this series, I introduced the series and covered the first part, Repeal.  In Part 2, Transition, I focused on a relatively simple transition plan for people currently covered under the ACA, including some of the financial math that would be associated with such a plan. In this Part 3, Replace, I focused on essential elements that would need to be included in a system to permanently replace the ACA.  In this Part 4, Looking Forward, I’ll get into 1) how repeal and replacement of the ACA could potentially be the main determinant of the outcome of the 2018 mid-term elections and/or the 2020 presidential election, and 2) what the future will probably look like under the replacement law if it is successful.

2018 and 2020 Elections Could Swing On Success Or Failure of the ACA Repeal/Replace Scenario

If repeal and replacement of the ACA is viewed as highly successful, that will favor continued and potentially even heavier Republican dominance. If is viewed as a total flop, that will favor at least some swing of the pendulum back toward Democrats.  Whether the outcomes of those elections are “sweeps” in either direction will depend on the perceived success or failure in other areas [immigration, terrorism, etc., but probably mostly the economy].

Note. Although the preceding paragraph assumes that the Current Paradigm will not fully “die” in another 2, maybe even 4 years, we must keep that factor in our thinking. A major acceleration in the paradigm shift underway, which I think is likely because of Mr Trump’s leadership style, would essentially erase the Republican/Democrat domination and change future elections dramatically [see the page A Major Paradigm Shift Well Underway at this site for a more in-depth description of this paradigm shift, and my blog post Election Aftermath – 1 for a confirmation that such a shift is underway].

It will be very interesting to see how the media characterizes both repeal and replacement. The extreme liberal bias in the media will no doubt result in second-guessing Trump and his administration at every point. The media’s strong supportive tone in reporting on Obama for the past eight years will turn into resistance and skepticism in its reporting on Trump. This will make Trump’s task in repeal and replacement much more difficult than Obama’s task in getting the ACA pushed through [i.e., Trump will have to not only produce a successful transition, but also counter negative press about it — much more challenging than having a press that is essentially a cheer-leading squad].

The Unfolding Of Healthcare From Here

There are two trends that I believe are imminent and will consume an increasing share of both financial and “mainstream” media coverage about Healthcare over the next few years.  Both would no doubt have occurred regardless of the presence or absence of the ACA or its replacement, for one simple reason: in 1960, Healthcare costs were 6% of the GDP; at the end of 2015 [most recent finalized data available], they were 17.8% and still rising. You don’t have to be a mathematician to understand that this is an exponential trend that not only will not, but cannot continue. Any component of the economy exhibiting that kind of exponential increase in the percentage of the GDP is headed for massive change, because continuation of that trend would ultimately result in that component completely dominating the economy and, over time, literally shutting down all other components.

Home Health And Other Alternate [Non-Hospital] Service Delivery Venues

One of these trends has to do with a major shift in how Healthcare services are delivered — specifically, a shift toward a substantially higher percentage of care that is delivered in venues other than hospitals. I believe hospital care will become more and more associated with very complex surgeries and other conditions that require intensive care and highly expensive equipment, that smaller hospitals will ultimately become more like networks of “remote emergency rooms” associated with large tertiary care hospitals, and that home-based care will become much more prevalent than it is today.

The trend toward alternate-venue delivery of healthcare services has actually been underway for well upwards of a decade [one evidence being the proliferation during that time of Urgent Care Centers, often staffed by Physician Assistants and Nurse Practitioners], but it is accelerating much more rapidly now. Also, more in-home service [Home Health] agencies are starting up, and existing ones are experiencing exponential growth.

The reason for this trend is no more complicated than cost containment. Hospitals have extremely high fixed costs when compared with those of alternate venues [particularly patients’ homes], and per-service costs in the alternate venues do not include allocations to cover those high fixed costs. Variable [labor and materials] costs are also higher in tertiary hospitals because of specialty staff and materials that have to always be available in them [this staff and those materials are not actually needed for many, many procedures].  Even when transportation costs [e.g., of medical professionals to patient homes] are accounted for, overall costs are still lower. As icing on the cake, it is quite possible that the quality of some alternate-venue services, all things considered, could actually be higher than the quality of services delivered in hospitals.

Massive Re-Engineering of the Healthcare Industry

The other trend I see on the horizon might actually be several different trends that could be viewed separately. I am grouping them into one because they will all be fueled by one main driver — the huge and rapidly growing need for improved overall effectiveness, a term I like to use to describe the ratio of quality divided by cost. Since there is no single number that reflects quality, this ratio does not exist, but referring to it conceptually is a concise way to define overall effectiveness — i.e.: if quality improves and cost remains constant, overall effectiveness [OE] increases; if quality remains constant and cost is reduced, OE increases; and [the ideal scenario] if quality improves and cost is reduced, OE increases dramatically.  This trend, then, can be thought of as a massive re-engineering of the Healthcare industry, not unlike what we have seen over the past few decades in other industries — notably manufacturing and mining.

Although considerable progress has been made in the past decade or so, Healthcare, in comparison to other industries, is still extremely inefficient. With all that technology has done to increase the OE of other industries, Healthcare is still a very “manual”, labor-intensive industry.  Granted, barriers to progress in Healthcare are probably more intense than in other industries [information security, for example], and risks of failure are more severe [loss of life from system failures rather than just recovery costs and/or lost revenue from outages in other industries], but the biggest barrier is burdensome regulation.  Getting into the details of that is beyond the scope of this blog post, but believe me, I wrestled with the Healthcare regulatory environment for decades. It’s like putting a boxer in the ring with one arm tied behind his back.

On the positive side, I believe the stage is now set for huge leaps in OE in Healthcare. Technology [telemedicine, more sophisticated yet less expensive testing methods, smartphones and smart watches and other “wearables”, smart homes and the “Internet of Things”, emerging standards for information interchange, more non-invasive “surgical” procedures …] is poised to facilitate massive functional changes, and the current leadership mindset of reducing government regulations, although mostly articulated in terms of environmental and financial regulations, will hopefully extend to Healthcare.

And Finally … Actually Dealing With Fraud and Abuse

Another factor that would contribute substantially to OE is virtual elimination of — not just reduction in — fraud and abuse [one notable example being providers who obtain reimbursements from Medicare and Medicaid based on fraudulently reported diagnoses and/or procedures]. This has become a standard claim of both Republican and Democrat candidates for at least the last six presidential election campaigns, and it has even been quantified by DHHS at $60 billion [that’s BILLION, with a “b”] in 2015. In my years as a senior executive in large regional healthcare systems, if I had told my Board that I had become aware of $16 million in unnecessary and avoidable expenses [about the same percent of annual budgets in those organizations as $60 billion is of the $3.8 trillion federal budget], particularly if they were related to fraud, it would have been OK if I had simultaneously articulated my plan for eliminating them in the current quarter. If I had said I just wanted them to be aware, and that I had formed a task force to look into the matter and fully quantify the problem and give me recommendations by the end of the current quarter to completely eliminate that waste in the next quarter, that might have been OK, too.  Had I then said in the next quarter that we were still researching the matter without simultaneously reporting at least some progress toward fixing the problem, I would have been fired on the spot. Only in government can a $60 billion [that we know of] problem be allowed to exist for decades and still be talked about by politicians as something that “we need to look into”.

Series Conclusion / Upcoming Plans For This Website

This post concludes this 4-part series that I entitled A Realistic View of the ACA.  Since this topic is so critical to the success of the Trump administration, I have decided to include the main content of Parts 2 [Transition] and 3 [Replace] in a new section of pages at this website that will focus on the future [Healthcare being only one of those areas of focus]. When that section’s content is ready for publication [which I’m currently targeting for sometime in January 2017], I will announce it in a blog post.  I have already drafted quite a few additions to the page that was originally the content of the Replace plan in Part 3 [some of those additions stemmed from reader comments].  Stay tuned!

Thanks!

 

Charles M. Jones

In Part 1 of this series, I introduced the series and covered the first part, Repeal.  In Part 2, Transition, I focused on a relatively simple transition plan for people currently covered under the ACA, including some of the financial math that would be associated with such a plan. In this Part 3, Replace, I’ll focus on essential elements that would need to be included in a system to permanently replace the ACA [trying to provide decent coverage of such a broad topic in an average-length post was impossible, so this one is a little longer].  In Part 4, Looking Forward, I’ll get into 1) how repeal and replacement of the ACA could potentially be the main determinant of the outcome of the 2018 mid-term elections and/or the 2020 presidential election, and 2) what the future will probably look like under the replacement law if it is successful.

Replace

Keep This In Mind …

To be meaningful and useful, outlining the essential elements that would need to be included in a system to permanently replace the ACA must be done in context with the Some Basics First section at the beginning of Part 2 of this series [A Realistic View of the ACA – Part 2]. If you review that section and overlay its conceptual framework on what I’ll be writing here, you’ll see that this post reflects my philosophy on the guiding principles I mentioned in that section. In a nutshell, I don’t believe that all Americans are entitled to some kind of “standard” level of health insurance [any more than I believe that all Americans are entitled to own a home, or to have a job they want, or to have an automobile, a telephone, …]. I do believe, however, that some government-mandated elements of a national healthcare system need to be in place, the main purposes of which would be: a) to ensure that all citizens are protected from financial ruin brought about by health problems; and b) to minimize the overall cost of providing all healthcare services, whether through government facilities and employees or through private sector providers. Under that basic philosophy, I will now list what I believe are the essential elements of an effective system that will not be the financial train wreck that the ACA is.

Essential Elements

NOTE. I am not asserting here that this simple outline fully defines the entire replacement system that would be needed. However, I do believe that it summarizes a conceptual approach that will work.

• (1) All insurance policies must cover the same time period [January 1 to December 31, or some other twelve-month period — calendar year will be assumed here], and all deadlines for signup must be the same.
• (2) By the same date each year, all insurance companies must submit electronically to DHHS a database of policies they will offer in the upcoming year, and those lists must contain a small amount of key information such as monthly premium, deductibles that must be met before any reimbursement begins, average co-pay ratio (e.g., 80% / 20%) for all situations where such ratios apply, primary physician visit co-pay, specialist visit co-pay, drug co-pays by “tier”, etc. [all of this would be very easy for any company to provide].
• (3) No insurance company can refuse to issue a policy to anyone based on their health status [e.g., pre-existing conditions].  This would clearly result in most insurance companies attaching astronomically high premiums to some of their policies, putting them out of financial reach for the vast majority of people who would need them. This issue will be addressed in subsequent items in this list. NOTE. Even Medicare is denied to people with end-stage renal failure at the time of their initial qualification for coverage. Allowing that criterion for this ACA replacement system should be investigated if elimination of those cases would have a material impact on overall costs.
• (4) If there are to be any mandated coverages [maternity, children under 26 can remain as dependents under their parents’ policies, abortion, gender change, etc.], all insurers who offer those kinds of benefits to any policyholders must offer optional riders in all policies they offer to anyone. One mandated coverage I believe would solve many problems and simplify this [or any] program greatly would be policies that provide catastrophic coverage only. For example: a much-lower-than-average premium; no coverage for anything up to $X, 80% insurance coverage / 20% patient copay from there to $Y, and 100% insurance coverage above $Y [the values of X and Y would have to be worked out, but I expect that values like $2,000 to $3,000 for X and somewhere between $10,000 and $20,000 for Y would result in premiums substantially lower than average and “maximum out of pocket” amounts at least as low as any current ACA-enabled policies, maybe lower].
• (5) Using statistical techniques [simple “bell curve” logic, standard deviations, etc. — far less sophisticated than techniques many government agencies use every day], DHHS will identify two groups of “outliers” in the policy database [i.e., policies that fall outside affordability limits set in the preceding year — see Ongoing Refinement section below].  One group of outliers will be called the Mandated Coverage Special Handling Pool [MCSHP], and will consist of people who are cost outliers and have applied for mandated coverage. The other group of outliers will be called the Cost Outlier Special Handling Pool [COSHP], and will consist of all other people classified as outliers.  For all of these outlier applicants [both groups], the following steps would be taken:

1. The applicable insurance companies would be issued letters of authorization to approve those policies at the average rate of all policies to be issued by that company in that year, with DHHS’ guarantee that it will reimburse them for all costs for those policies that are over and above their average costs for all other claims paid during that year.
2. All SHP applicants will be issued letters from DHHS [or from the companies to which they applied if that is more practical] outlining their options: 1) proceed with enrollment [which would put them in the same status as anyone else who was not put in the SHP, including determination of their qualification for any other governmental financial assistance that may apply to them]; or 2) refuse this offer of government assistance over and above any other assistance for which they may otherwise qualify.
3. Through dialog with each SHP policyholder who elected to go ahead and enroll, DHHS would: 1) determine whether or not they qualify for any other governmental financial assistance that may apply to them; 2) attempt to identify other coverage options that would provide equivalent or better benefits while lowering the government’s projected costs to support their policy; and 3) implement any decisions resulting from this interaction.

• (6) A determination will be made as to income levels [and/or other criteria] at which government assistance should be offered, and what that assistance will be.  If such an assistance program is included, it will be implemented through income tax credits [not just deductions from income] and a mechanism for providing those credits through payroll withholding credits for employed people or through additions to any unemployment or other [disability, etc.] payments for others. NOTE. The details of this would have to be worked out in conjunction with changes in the Tax Code that will likely be underway at the same time.
• (7) All insurers will submit an annual report to DHHS to include total revenues from policyholders, total reimbursements from government, other revenues, total cost of claims paid [and maybe expenses “incurred but not reported”, or IBNR, depending on how long after year-end the report is due], etc. Data for these reports would be readily-available within these organizations, so the reporting [which should be common-format electronic data, not paper] would not be burdensome. A similar reporting requirement for providers might also be advisable if that information would enhance the usefulness of the information obtained from insurers.
• (8) At some point in the future, when more viable measures of quality are available and more effective ways to incorporate them into insurance policy comparisons have been developed, quality parameters should be integrated into this entire process [attempting to do this now could actually be detrimental without better measures than we have at this time].
• (9) The above items are operational in nature. Other possibilities for reducing overall healthcare costs that should be investigated would include but not be limited to the following [some of these are controversial; to the extent those controversies are simply driven by “wars among lobbyists”, that more fundamental issue will need to be dealt with before meaningful progress can be made]:

1. Imposition of maximum increases or mandated reductions in a given year.  This would have to be purely data-driven, not fully controlled by politicians, and some “appeal” process would be necessary.
2. Removal of state-level boundaries for insurers. Allow the sale of national policies, regional multi-state policies, etc.
3. Promulgation of Tort Reform. Curb sometimes ridiculous jury awards, but in a way that does not adversely affect accountability. This is much more costly than the awards themselves — the bigger cost is in “defensive medicine” [tests ordered and procedures performed by providers to avoid potential lawsuits even when they would not, absent the threat of litigation, consider those tests and procedures medically necessary].
4. Identification of ways to curb “blockbuster” drug costs without thwarting innovation within companies that develop them.
5. Improvement of capabilities to curb fraud and abuse in all entitlement programs as well as in this new ACA replacement system.

Program Administration

On the administrative side, the massive organization put in place under the ACA would be dismantled as soon as possible, leaving a much-reduced, very streamlined management structure and a much smaller staff consisting of current employees having skills most applicable to administration of the new law, plus any new hires required to ensure an appropriately skilled workforce.

Ongoing Refinement

Certain elements of this program would require an ongoing effort to adjust various parameters each year to ensure that they remain current. One example would be computation of the “outlier” definition mentioned in #5 in the Essential Elements section above.  In the first year, the information in the ACA database for the 2017 enrollment period would be used to establish a baseline database for the new law [see #2 in the Essential Elements section above for a description of the kinds of information that database would contain].

Another area that needs more focused research right now as well as ongoing refinement over time is identification of more viable measures of quality and development of ways to incorporate use of these measures into insurance policy comparisons. Despite much time and effort along these lines over many years, the truth is that current measures simply do not adequately account for variations in patient conditions and other factors that can grossly skew current measures like mortality rates, unexpected returns to surgery, patient satisfaction scores, etc.

Potential Roadblocks

To repeal, and to replace, the ACA will require “lock-step” solidarity among almost all Republicans in the House and at least 50 of the 52 in the Senate [just as initial passage of the ACA required that of all Democrats at that time]. Assuming that all Democrats will be in solidarity with their opposition, this may be tougher than some legislators think at this time.  Also, there may be certain provisions that may raise the specter of a presidential veto even though a Republican will be in the White House. This may turn out to be a textbook example of Mr. Trump’s deal-making ability — or an example of lack thereof as it could potentially apply to this situation.

On the prospect of filibusters as a blocking mechanism … Minority-party threats of filibusters have become so commonplace over the past two years that many people probably think that a less-than-60-seat majority in the Senate enables the minority party to block forever [by threatening filibusters] any bill they oppose, rendering the majority party completely powerless to drive its agenda. That is not the case, however, and the first two years of the Trump administration could produce a major breakthrough in the gridlock of recent years if Republicans are as unified in their agenda as Democrats have been in blocking it. The decision by a majority leader to bow to the threat of a minority-party filibuster is a simple practical matter — avoiding an actual filibuster, which can consume many days, perhaps longer, before the majority leader can bring “cloture” about [the last step that results in the bill being brought before the full Senate for a vote], frees up time for passage of other more bipartisan bills which have greater prospects of being passed.  With a minority-party President who would likely veto narrowly-passed controversial bills, that decision is probably a wise one.   If there has ever been a time when the majority needs to stand up to filibuster threats and do whatever it takes to drive key pieces of its agenda through, this is it!  If a bill is particularly important to the Senate majority and its legislative agenda [and/or the president’s agenda], then going through a filibuster would be worth it and would expose very publicly that it’s the minority that’s causing the logjam.

Note. For anyone interested in gaining a more in-depth understanding of Senate rules and operations as they relate to filibusters and cloture, the document at this link would be a good start: Senate Filabuster & Cloture Rules.

Why This Replacement Approach?

The main advantages in taking this general approach are not that difficult to figure out:

• Rather than micromanaging every citizen’s healthcare coverage, it focuses the government’s attention [and expenditures] on problem situations [a) all citizens who cannot obtain any coverage, and b) all citizens whose coverage options are financially out of their reach and who qualify — based on all applicable criteria, not just those associated with healthcare — for government assistance].
• It allows for mandated coverage items that will probably be required to get the law passed in both houses of the Legislature, particularly the Senate, and it keeps the direct costs of those mandates visible every year.
• It keeps cost outlier criteria current every year, providing a) a more efficient and more expeditious method of adjusting them to changing conditions and b) better information for identifying the actual cost to the program of egregious pricing for certain items like “blockbuster” drugs, “exotic” prostheses, etc. [currently, these situations become visible through media coverage of specific situations, and the resulting politicization (politicians continuously engaged in “issue-hunting”)].
• The overall cost, the administrative complexity, and the size of the bureaucracy required to administer the program, would be dramatically lower [largely because of the previous items in this list].

There are probably other advantages, but those listed above are enough to warrant taking this approach.

In Part 4 …

In Part 4, Looking Forward, I’ll get into 1) how repeal and replacement of the ACA could potentially be the main determinant of the outcome of the 2018 mid-term elections and/or the 2020 presidential election, and 2) what the future will probably look like under the replacement law if it is successful.

Thanks!

 

Charles M. Jones

In Part 1 of this series, I introduced the series and covered the first part, Repeal.  After writing this Part 2 and realizing that discussion of a Transition Plan required a few more words than I originally thought it would, I decided to expand the series to four parts instead of three. So, this Part 2 will focus mainly on a relatively simple Transition Plan for people currently covered under the ACA, and some of the financial math that would be associated with such a plan.  Part 3, Replace, will focus on the essential elements that would need to be included in a new plan defined by a law replacing the ACA, and Part 4 will focus on Looking Ahead [after passage of a law replacing the ACA].

Some Basics First

In the process leading to proposed law being voted on in both houses of the Legislature, there is an unfortunate reality we have to face — that bills get to this point only after huge amounts of political bargaining among Representatives and Senators whose primary focus is not on what is best for America, but on what most likely leads to their reelection. For that reason, the most important part of the process is bypassed — determining first what guiding principles can be agreed upon up front before hashing out of the details even begins. In the case of coming up with what became the ACA, or of coming up with a law to replace all or parts of it after its repeal, that would mean addressing fundamental questions like the following:

• Is every American citizen entitled to insurance to cover their healthcare needs, or is it simply a product/service that some people can afford and others can’t?
• If healthcare insurance is an entitlement, which products/services are considered entitlements, and should the government provide them directly through government-run facilities or pay private providers for their costs and reasonable profits to provide them [and in the latter case, how will guaranteed access and affordability be ensured for people private insurers deem unprofitable to cover]?
• If healthcare insurance is not an entitlement, should there be regulations that require access to healthcare services under certain conditions by people who cannot afford to pay for those services [and if so, what are those conditions, and is government required to either pay for that access (through tax revenues) or require providers to absorb the unreimbursed costs they incur in providing them (a form of indirect taxation)]?
• In either case, for any financial assistance that may be available under certain conditions, do people who do not manage their own health well [eating habits, exercise, etc.] receive the same assistance as those who do [and if not, on what basis is the granting of assistance made, and who makes that decision]?

Although most legislators would probably say they did address or are addressing fundamental questions like these, they haven’t done so in the way and to the depth I’m saying they should have.

Replace

Given this caveat, we’ll look at two things that replacement legislation needs to address: 1) a transition plan for people currently covered under plans obtained through the ACA; and 2) essential elements of a replacement law. As mentioned above, I’ll focus on the latter in Part 3, Replace.  In this Part 2, I’ll focus on a plan for Transition.

Transition Plan

This isn’t rocket science — a lot of what is needed is simply common sense.  Politicians have a tendency to get bogged down in peripheral arguments, particularly when they perceive that a decision they are about to make will affect large numbers of people and/or when they recognize the risks involved and the possibility that they and/or their party will be blamed [and punished in the next election] if things don’t go well.  I call this the Mesmerization Syndrome.  A good example is what has already become a headline item — “Repealing the ACA will kick 20 million people off their health plans”.  Something I said in Part 1 of this series is worth repeating in this context. … Although there are, in fact, about 20 million people now enrolled through the exchanges set up under the ACA, nobody knows how many of these people have coverage through the ACA because they could not obtain coverage without the ACA.  It would not surprise me if it turns out that only half, maybe even less, would not be able to obtain more or less comparable coverage — i.e., many enrollees probably bought through the exchanges for other reasons [e.g., they found it easier to navigate through their options once the initial glitches were ironed out]. Whatever the actual number of people affected turns out to be, all that is needed initially to avoid this “kicking off” is a simple set of transition rules built around a common-sense “grandfather clause” something like the following:

“Grandfather Clause“  Any existing policy obtained under provisions of the ACA cannot be terminated by the insurer, nor can its renewal be refused until the replacement law is in effect, except for 1) non-payment of premiums; 2) or non-payment of co-pays, deductibles, etc. within “x” days of due dates [unless disputed — with a defined process for resolving disputes].

According to www.healthcare.gov [the site where people can “shop” for and sign up for plans under the ACA], the average 2017 cost of a “gold” plan [the best plans available] will be $9,167. Even if all 20 million enrollees were grandfathered in for all of 2017 and all 20 million qualified for 100% government-subsidized coverage [an extremely exaggerated, almost facetious assumption], the cost of this transition would only be 183.34 billion [in the general range of what would be spent under an unmodified ACA] .  Realistically, the cost would be less than that because based on the highest estimate I’ve seen, only about 83% of people enrolled under the ACA qualify for government subsidies [the average amount of individual subsidies is a difficult number to find, but it is certainly nowhere near 100%]. Also, as mentioned above, it is only people who otherwise would not be able to obtain coverage [i.e., not the whole 20 million] who would need to be included in this calculation. It would not surprise me at all if the actual cost of this “grandfather clause” transition turned out to be considerably less than $100 billion.

Essential Elements of a Replacement Law

I’ll get into this in Part 3, Replace. Then, in Part 4 of this series, which will be focused on Looking Forward, I’ll get into 1) how repeal and replacement of the ACA could potentially be the main determinant of the outcome of the 2018 mid-term elections and/or the 2020 presidential election, and 2) what the future will probably look like under the replacement law if it is successful.

Thanks!

 

Charles M. Jones