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Health Care Reform Efforts Throughout History
Not Just Obamacare: Medicaid, Medicare Also On GOP’s Chopping Block
rious about repealing Obamacare, and doing so quickly. But don’t assume their dismantling of government health insurance programs will stop there.
For about two decades now, Republicans have been talking about radically changing the government’s two largest health insurance programs, Medicaid and Medicare.
The goal with Medicaid is to turn the program almost entirely over to the states, but with less money to run it. The goal with Medicare is to convert it from a government-run insurance program into a voucher system ― while, once again, reducing the money that goes into the program.
House Speaker Paul Ryan (R-Wis.) has championed these ideas for years. Trump has not. In fact, in a 2015 interview his campaign website highlighted, he vowed that “I’m not going to cut Medicare or Medicaid.” But the health care agenda on Trump’s transition website, which went live Thursday, vows to “modernize Medicare” and allow more “flexibility” for Medicaid.
In Washington, those are euphemisms for precisely the kind of Medicare and Medicaid plans Ryan has long envisioned. And while it’s never clear what Trump really thinks or how he’ll act, it sure looks like both he and congressional Republicans are out to undo Lyndon Johnson’s health care legacy, not just Barack Obama’s.
f course, whenever Trump or Republicans talk about dismantling existing government programs, they insist they will replace them with something better ― implying that the people who depend on those programs now won’t be worse off.
But Republicans are not trying to replicate what Medicaid, Medicare and the Affordable Care Act do now. Nor are they trying to maintain the current, historically high level of health coverage nationwide that these programs have produced. Their goal is to slash government spending on health care and to peel back regulations on parts of the health care industry, particularly insurers.
This would mean lower taxes, and an insurance market that operates with less government interference. It would also reduce how many people get help paying for health coverage, and make it so that those who continue to receive government-sponsored health benefits will get less help than they do now.
It’s difficult to be precise about the real-world effects, because the Republican plans for replacing existing government insurance programs remain so undefined. Ryan’s“A Better Way” proposal is a broad, 37-page outline without dollar figures, and Senate Republican leaders have never produced an actual Obamacare “replacement” plan.
But the Republican plans in circulation, along with the vague ― and shifting ― health care principles Trump endorsed during the campaign, have common themes. And from those it’s possible to glean a big-picture idea of what a fully realized version of the Republican health care agenda would mean.
20 Questions for President Trump
The last six and a half years have been uncharted territory in our nation’s century-long debate over health reform. For the first time the fight was about how to implement an attempt at near-universal coverage rather over what this plan should look like and what could win enough support in Congress. The Affordable Care Act (ACA) has survived major political, legislative, and legal tests, including dozens of repeal votes, two Supreme Court decisions, the 2012 presidential election, and state-level resistance.
I was outside the Supreme Court on June 25, 2015 when the King v. Burwell decision was released. I was there the moment activists switched their signs from saying “Don’t you dare take my care” to “The ACA is here to stay.” I wrote that we could finally say with some certainty that they were right, the law is here to stay. They were wrong. I was wrong.
Donald Trump’s victory throws the future of health reform into complete chaos. He will take office in January 2017 with Republican majorities in the House and Senate. President Trump, Speaker Ryan, and Senate Majority Leader McConnell have all made repeated promises to get rid of Obamacare. They will face enormous pressure to follow through with their threats of repeal. Approximately 21 million people are projected to lose insurance if they follow through with their initial proposals.
The first step to figuring out where to go from here is understanding what decisions are on the horizon. Here are my first 20 questions about health reform under the Trump administration , in no particular order:
True value-based care is a trillion-dollar unicorn for the health care industry
True value-based care is a trillion-dollar unicorn for the health care industry
In Silicon Valley, Kendall Square, and points in between, unicorns are more than mythical creatures that adorn software engineers’ ironic T-shirts. They’re disruptive technology behemoths with billion-dollar-plus valuations. These beasts have largely shied away from the health technology sphere over the last decade, despite many promising upstarts. Maybe we’ve been hunting for the wrong kind.
Get ready for the uber-unicorn. It won’t be a single, enormous company with a trillion-dollar valuation. Instead, it’s a movement called value-based care.
Value-based care isn’t a new concept. But it’s been used a bit bashfully, traditionally referring to carrot-and-stick-based incentive payments and penalties for physicians. Today these pale in comparison to the fee-for-service care that rewards reactive, episodic, paternalistic care — and lots of it.
Here’s what I mean by true value-based care: fully capitated payment contracts in which a lump sum of money is available to treat a patient over the course of a year. No penalties or incentives, simply ownership of the total cost of care and the total cost of outcomes. The better the care, the more money the organization bearing the risk receives. This is how to best reward exceedingly efficient, effective health care.
What Would Block Grants or Limits on Per Capita Spending Mean for Medicaid?
http://www.commonwealthfund.org/publications/issue-briefs/2016/nov/medicaid-block-grants
ABSTRACT
Issue: President-elect Trump and some in Congress have called for establishing absolute limits on the federal government’s spending on Medicaid, not only for the population covered through the Affordable Care Act’s eligibility expansion but for the program overall. Such a change would effectively reverse a 50-year trend of expanding Medicaid in order to protect the most vulnerable Americans.
Goal: To explore the two most common proposals for reengineering federal funding of Medicaid: block grants that set limits on total annual spending regardless of enrollment, and caps that limit average spending per enrollee.
Methods: Review of existing policy proposals and other documents.
Key findings and conclusions: Current proposals for dramatically reducing federal spending on Medicaid would achieve this goal by creating fixed-funding formulas divorced from the actual costs of providing care. As such, they would create funding gaps for states to either absorb or, more likely, offset through new limits placed on their programs. As a result, block-granting Medicaid or instituting “per capita caps” would most likely reduce the number of Americans eligible for Medicaid and narrow coverage for remaining enrollees. The latter approach would, however, allow for population growth, though its desirability to the new president and Congress is unclear. The full extent of funding and benefit reductions is as yet unknown.
New 11-Country Health Care Survey: U.S. Adults Skip Care Due To Costs, Struggle Financially, And Have The Worst Health
http://www.commonwealthfund.org/publications/press-releases/2016/nov/international-survey-release
A new 11-country survey from The Commonwealth Fund finds that adults in the United States are far more likely than those in 10 other high-income nations to go without needed health care because of costs and to struggle to afford basic necessities such as housing and healthy food. The survey findings, published today as a Health Affairs Web First article, also indicate that Americans are sicker than people in other countries and experience high levels of emotional distress.
Despite a significant decline from 2013, about one-third (33%) of U.S. adults went without recommended care, did not see a doctor when sick, or failed to fill prescriptions because of cost. By comparison, as few as 7 percent in the U.K. and Germany and 8 percent in the Netherlands and Sweden experienced these cost problems. The U.S. also stands out for its exceptionally high rate of material hardship. Fifteen percent of U.S. adults reported worrying about having enough money for nutritious food and 16 percent reported struggling to afford their rent or mortgage.
Adults in the U.S. were also the most likely to be in poor health. More than a quarter (28%) of U.S. respondents reported having multiple chronic illnesses—by far the highest rate of any country surveyed—and a similar proportion (26%) said they experienced emotional distress in the past year that was difficult to cope with on their own. Respondents in Canada (27%) and Sweden (24%) reported similar levels of emotional distress.
The Commonwealth Fund’s 2016 international survey interviewed 26,863 adults from Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States. Questions focused on people’s experiences with their country’s health care system—comparing their assessments of health care access, quality, and affordability—as well as on self-reported health and well-being. The study’s authors note that by examining the variation in performance of national health systems, the U.S. can gain useful insights as it implements new reforms and seeks to meet the needs of vulnerable patients.
“Previous surveys have shown that, especially compared to other industrialized nations, the U.S. has far too many people who can’t afford the care they need, even when they have health insurance,” said Robin Osborn, Vice President and Director of The Commonwealth Fund’s International Program in Health Policy and Practice Innovations and the study’s lead author. “This survey underscores that we can do better for our sickest and poorest patients, and that should be a high priority in efforts to improve our current system.”
