Tag Archives: ACA

Health care fixes miss the mark

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http://www.detroitnews.com/story/opinion/2017/04/23/valenti-health-care/100822732/

 

 

The phrase “repeal and replace Obamacare” might be in the news, but any new legislation regarding it means little for Michiganians.

Obamacare and the Republicans’ fix, the American Health Care Act, are almost entirely focused on the individual insurance market, yet the majority of Americans receive employer-sponsored health insurance coverage. More importantly, more than one million Metro Detroiters are covered by employers who “self-fund” or self-insure their employee health care benefits.

What does self-insure mean? It means your employer pays, right out of its annual budget, 100 percent of employee medical claims. Your card might read Blue Cross Blue Shield or Aetna, but the insurance company is simply the administrator who collects the claims and sends them off to your employer for payment.

Regardless of who is paying, rising health care costs are the No. 1 threat to American prosperity. Health care costs forced General Motors, Chrysler and the city of Detroit into bankruptcy; health care costs are the main reason wages have not grown in 20 years; and, Michigan spends 40 percent (and growing) of its annual budget on health care — crowding out spending on everything else.

But fixing our health care cost problem today doesn’t require a single action from Congress. Instead of marching on Washington and yelling at elected officials, we should be talking to our CEOs and heads of human resources.

Self-insured employers have tremendous power to change health care. Most employers simply outsource health care benefit construction to consultants and brokers — the same people who are compensated to perpetuate our high-cost health care status quo.

When the lame, status quo attempts at cost-control fail, the usual employer response is to cut, cut, cut. They resort to using an axe to prune rose bushes; high deductible health plans are blunt force instruments that do not sustainably control health care costs and will eventually exacerbate our cost problem.

Indeed, a few, truly innovative employers are providing better employee benefits and reducing health care costs 20-50 percent. If everyone followed their lead, it could result in $2,500 to $5,000 annual raises for each of us and immediately pump $2 billion to 4 billion into the Metro Detroit economy every year.

The solution isn’t a secret. In fact, a non-profit/501(c)(3) called the Health Rosetta was formed to publicize the simple fixes. The organization was spurred by a concerned citizen and the former global head of Microsoft’s health care business named Dave Chase.

The Health Rosetta identifies a few, easy to implement, specific improvements, the most important of which focuses on the intake or front-end of the system: primary care. Hence, the Health Rosetta’s foundation is called Value-Based Primary Care or Direct Primary Care. Other improvements are then built on top, such as “Transparent Medical Markets,” where patients receive up-front pricing and even quality guarantees on a range of surgeries and procedures.

These are the kinds of solutions employers should be considering as everyone wrestles with skyrocketing health care costs.

Tom Valenti is the founding partner of Forthright Health.

Can Obamacare Survive Another Round in the Congressional Boxing Ring?

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http://www.realclearhealth.com/articles/2017/04/25/can_obamacare_survive_another_round_in_the_congressional_boxing_ring_110564.html?utm_source=RC+Health+Morning+Scan&utm_campaign=2fcc8f4477-EMAIL_CAMPAIGN_2017_04_25&utm_medium=email&utm_term=0_b4baf6b587-2fcc8f4477-84752421

Can Obamacare Survive Another Round in the Congressional Boxing Ring?

The Affordable Care Act (ACA) has survived its biggest challenge to date with the failed attempt to repeal and replace by the GOP. But will it survive in the long run? Republican comments and President Trump’s many tweets would suggest the law is still doomed. It is hard to predict what will happen, but let’s examine some themes we are seeing so far to try to gain some insight:

One of the first things the GOP Congress wanted was to retract the cost sharing payments to insurers for low-income exchange plan members. Without these payments, insurers would lose even more money, driving many of them to not offer plans in the state exchanges. The jury is still out on whether the replacement bill’s failure will move the budget reconciliation process forward, but insurers have only two months to decide if they will provide a plan in the exchanges for 2018. If insurers do decide to stay in the exchanges, significant premium increases are very likely to help cover their costs. This will force many people who cannot afford the monthly cost to drop out of coverage. Either of these situations would push people back into the uninsured ranks where providers would lose that reimbursement revenue and drive up uncompensated care.

Loosening the individual mandate’s enforcement is another theme being discussed. New HHS Secretary Price has stated he plans to allow states to loosen the restrictions on waivers for the individual mandate. Combined with premium increases, this would allow people to opt out of coverage much more easily. The CBO report has stated 7 million people would have opted out of coverage if the American Health Care Act (AHCA) had been passed, since many people do not think they need it. Most of these people would be younger and healthier, creating higher costs for insurers, while driving up premiums and/or driving insurers to exit the exchange.

Secretary Price has also mentioned giving states the ability to set requirements to individuals to maintain Medicaid coverage, like applying for work. Studies have shown in the past this activity causes people to fall out of coverage. It is expected that this move would cause many to fall off the Medicaid roles and drive them to the uninsured ranks as well.

The federal deficit is upwards of $540 billion for 2017. And If the ACA does not change at all, then the federal government is expected to spend $1.2 trillion on Medicaid coverage alone through 2026. Previous CBO estimates indicate this would drive our yearly national deficit to over a trillion dollars in 10 years. The U.S. economy survives today because financial institutions buy treasury bonds to fund that deficit each year. But when deficits reach the heights predicted if the ACA remains entirely intact, and the national debt reaches a significant portion of our yearly GDP, bond sales could and likely will slow down. That means damage to the U.S. economy as it continues to stabilize post-recession.

A federal budget has been submitted that makes some spending cuts, but without the AHCA’s passage they pale when faced with the real problem of balancing our budget. This is not an indictment of policy to cover people with insurance, but simply a fact that our nation must find a way to balance our finances. There are many ways to cut cost, but the GOP seems fixated on cutting Medicaid spending as the key to accomplishing this.

We can only theorize what might become of the ACA, but looking at some of the themes and recent comments by the current administration, it would appear some things will change if not a complete revisit of the repeal and replace bill. Will those changes effectively kill the law since it will lack the ability to function as planned? Quite possibly, but only time will tell.

Change will happen. It will result in some sort of reimbursement cuts and very likely push more people back to the uninsured roles. Providers need to ready themselves, and start thinking about ways to improve productivity and reduce the cost to collect while increasing cash collections.

Shawn Yates serves as Director of Product Management for Ontario Systems, defining the company’s strategy for product and service offerings in the health care market. With over 20 years of experience managing self-pay receivables and collection operations for a top 20 health care system, Shawn’s background also includes working for a national outsourcing company helping clients manage their insurance and self-pay receivables, and Experian Health, the largest data and analytics company in the country.

The views above belong solely to the author.

California Employer Health Benefits: Prices Up, Coverage Down

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http://www.chcf.org/publications/2017/03/employer-health-benefits?utm_source=CHL&utm_content=From%20The%20Foundation&utm_campaign=Footer

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Since 2000, the percentage of employers offering health benefits has declined in California and nationwide, although coverage rates among offering firms have remained stable. Only 55% of California firms reported providing health insurance to employees in 2016, down from 69% in 2000. Implementation of the Affordable Care Act (ACA) in 2014 does not appear to have impacted the overall trend in employer offer rates.

Nineteen percent of California firms reported that they increased cost sharing in the past year, and 27% of firms reported that they were very or somewhat likely to increase employees’ premium contribution in the next year. The prevalence of plans with large deductibles also continues to increase.

California Employer Health Benefits: Prices Up, Coverage Down presents data compiled from the 2016 California Employer Health Benefits Survey.

 

Drugmakers Dramatically Boosted Lobbying Spending In Trump’s First Quarter

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Drugmakers Dramatically Boosted Lobbying Spending In Trump’s First Quarter

Eight pharmaceutical companies more than doubled their lobbying spending in the first three months of 2017, when the Affordable Care Act was on the chopping block and high drug prices were clearly in the crosshairs of Congress and President Donald Trump.

Congressional records show those eight, including Celgene and Mylan, kicked in an extra $4.42 million versus that quarter last year. Industry giant Teva Pharmaceutical Industries spent $2.67 million, up 115 percent from a year ago as several companies embroiled in controversies raised their outlays significantly.

“It’s certainly a rare event” when lobbying dollars double, noted Timothy LaPira, an associate professor of political science at James Madison University. “These spikes are usually timed when Congress in particular is going to be really hammering home on a particular issue. Right now, that’s health care and taxes.”

Trump has come down hard on drugmakers, stating in a press conference before his inauguration that the industry is “getting away with murder.” He has promised to lower drug prices and increase competition with faster approvals and fewer regulations. Sens. Bernie Sanders (I-Vt.) and John McCain (R-Ariz.), and Rep. Elijah E. Cummings (D-Md.) have introduced bills to allow lower-cost drug imports from Canada or other countries.

Lobbyists weren’t expecting much by way of big policy changes during the comparatively sleepy end of the Obama administration this time last year, but with a surprise Trump administration and a Republican-controlled House and Senate, trade groups and companies are probably “going all in,” LaPira said.

Thirty-eight major drugmakers and trade groups spent a total of $50.9 million, up $10.1 million from the first quarter of last year, according to a Kaiser Health News analysis. They deployed 600 lobbyists in all.

PhRMA, the drug industry’s largest trade group, spent $7.98 million during the quarter —more than in any single quarter in almost a decade, congressional records show, topping even its quarterly lobbying ahead of the Affordable Care Act’s passage in 2010.

In their congressional disclosures, companies listed Medicare price negotiation, the American Health Care Act, drug importation and the orphan drug program as issues they were lobbying for or against. They do not have to disclose on which side of an issue they lobbied.

When Medicare prices are on the table, it should come as no surprise that pharmaceutical companies are interested in influencing congress.

“It’s quite literally hitting their bottom line,” LaPira said.

Drugmakers under fire more than doubled their lobbying dollars. Mylan spent $1.45 million during the quarter, up from $610,000 last year. The company’s CEO faced a congressional hearing in the fall when it raised the price of EpiPen to over $600.

Marathon Pharmaceuticals spent $230,000, which was $120,000 more than last year. Marathon was criticized in February after setting the price of Emflaza, a steroid to treat Duchenne muscular dystrophy, at $89,000 a year. That angered advocates, Congress and patients who had been importing the same drug for as little as $1,000 a year. Marathon has since sold the drug to another company, and the price may come down.

Teva and Shire also more than doubled their spending. Teva was accused as part of an alleged generic price-fixing scheme in December, and the Federal Trade Commission sued Shire because one of its recently acquired companies allegedly filed “sham” petitions with the Food and Drug Administration to stave off generics.

Companies that make drugs for rare diseases also more than doubled lobbying dollars as congressional leaders and the Government Accountability Office work to determine whether the Orphan Drug Act is being abused. Those firms include BioMarin, Celgene and Vertex Pharmaceuticals. Celgene, which makes a rare cancer drug, more than tripled its first quarter lobbying to more than $1 million.

Despite efforts to make good on campaign promises to repeal the Affordable Care Act, House Republicans canceled a floor vote on the American Health Care Act in March after multiple studies estimated that millions of people would lose coverage if it passed, and neither Democrats nor ultra-conservatives lined up in opposition to the bill’s provisions. Drug prices weren’t a key part of the package.

 

GOP to give Obamacare repeal another shot next week

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http://www.healthcarefinancenews.com/news/gop-give-obamacare-repeal-another-shot-next-week

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The Republicans have a new plan to repeal and replace the Affordable Care Act, according to reports.

The new bill is expected to be out by the weekend and to get a vote by the mid-week in time for the president’s first 100 days, according to Politico. Sources told Politico they believe they are close to having the votes necessary to pass the bill.

House Speaker Paul Ryan pulled the previous bill, the American Health Care Act, when it became clear there were not enough votes for it to pass because of opposition from members of the conservative Freedom Caucus.

On April 13, Republican Representatives Tom MacArthur, a Republican from New Jersey, and Mark Meadows, who heads the Freedom Caucus seemed to come to a compromise on an amendment that gives states more flexibility while preserving consumer protections to get and retain health insurance.

The MacArthur Amendment to the American Health Care Act would reinstate essential health benefits as the federal standard, but would allow states to apply for a waiver for these essential health benefits as a way to reduce premium costs.

State waivers could also be applied for community rating rules that prevent insurers from varying premiums within a geographic area, except for factors of gender, health status and age. The later would have the exception of the 5:1 age ratio for older Americans.

Under the amendment, health status is also up for an exception in states that establish a high-risk pool or are participating in a federal high-risk pool.

It would prohibit denial of coverage due to preexisting medical conditions, guarantee coverage and renewal of coverage, and allow dependents to stay on their parents’ plans up until the age of 26 years old.

In mid-April, House Speaker Paul Ryan unveiled an amendment to the American Health Care Act that would create a federal risk sharing program for insurers.

Before the break, a House Rules Committee approved a mark-up of the amendment.

Ryan gave no cost to the amendment sponsored by conservative Reps. Gary Palmer of Alabama and David Schweikert of Arizona. Palmer said the Palmer-Schweikert proposal is modeled after what is being done in Maine. The risk-sharing program would be a federal program for three years and then turned over to the states, Palmer said.

In 2011, Maine overhauled its system, creating what is called an invisible high-risk pool for individuals with pre-existing conditions. The invisible high-risk pool was made of up individuals who had certain conditions that would have normally placed them in a regular high-risk pool.

However, these individuals did not know they were in the invisible high-risk pool and were not charged higher premiums. The invisible high-risk pool operated behind the scenes as the Maine Guaranteed Access Reinsurance Association.

 

Revised ACA Repeal-and-Replace Bill Likely to Increase the Uninsured Rate and Health Insurance Costs for Many

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http://www.commonwealthfund.org/publications/blog/2017/apr/amendment-aca-repeal-and-replace-bill

News outlets report that House Republicans are close to agreeing on an amended version of the American Health Care Act (AHCA), their proposed repeal and replacement of the Affordable Care Act (ACA). The all-important legislative language for the revised bill is not yet available, nor are Congressional Budget Office (CBO) projections of its effects on coverage and the budget, so any analyses are necessarily tentative.

Nevertheless, the summaries leaked to the media offer insight on the amended bill. If accurate, those summaries suggest that the revised AHCA will significantly increase the numbers of uninsured Americans, raise the cost of insurance for many of the nation’s most vulnerable citizens, and, as originally proposed in the AHCA, cut and reconfigure the Medicaid program. The new amendment specifically allows states to weaken consumer protections by, for example, permitting insurers to charge people with preexisting conditions higher premiums.

What the Amendment Leaves in Place

The amended proposed bill does little to change many provisions of the original AHCA including:

The CBO estimated in March that the combined effects of these provisions would increase the number of people without health insurance by 24 million by 2026. Older Americans would be particularly hard hit by the bill, experiencing much higher premiums relative to the ACA and the greatest coverage losses.

What the Amendment Changes

The amendment offers states the option to apply for waivers to reduce ACA consumer protections that have enabled people with health problems to buy private health insurance. States could waive the ban on charging people with preexisting conditions higher premiums, as long as states set up high-risk pools for people with conditions like cancer or heart disease who could no longer afford coverage. States could also change the ACA’s required minimum package of health benefits for health plans sold in the individual and small-group markets.

Despite the fact the federal ban on preexisting condition exclusions would remain under the AHCA, as Tim Jost points out, insurers could reach the same end by not covering services like chemotherapy that sick people need, or by charging very high premiums for individuals with expensive, preexisting problems. In addition, waiving the ACA’s essential benefit requirement could weaken other consumer protections like bans on lifetime and annual benefit limits and caps on out-of-pocket costs.

While states that allowed higher premiums for people with health problems would be required to use a high-risk pool under the amendment, prior research has found that such pools operated by states before the ACA were expensive both for states and for people enrolled in them, and covered only a small fraction of the individuals who would have benefited. An amendment proposed earlier in the month would provide federal funds for a so-called “invisible risk-sharing” program, a hybrid between a high-risk pool and reinsurance for high claims costs, but the allocated funding would likely need to be much higher to have an impact on costs.

The number of states that would apply for these waivers is unknown, but it seems reasonable to expect that many states with governors and legislatures that have opposed the ACA would do so. For a substantial part of the country, therefore, the amendment could seriously undermine the ACA’s protections for people with preexisting health conditions.

 

White House, Republican leadership downplay chances of quick healthcare deal

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‘Iranians are no threat to Americans’: Ann Coulter blasts Trump focus on Iran instead of ‘this hemisphere’

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White House officials and Republican aides worked to downplay expectations of an imminent vote on Obamacare reform legislation Thursday amid widespread speculation that a healthcare deal was in the offing.

While both the White House and GOP aides confirmed that healthcare negotiations have continued throughout the congressional recess, both sides stressed that a compromise bill may not be ready for a vote by next week, when lawmakers return from their two-week break.

“Congress needs to act quickly on a solution for the American people. Our administration is engaged in those conversations and we are making progress,” a White House official told the Washington Examiner. “But there is not a set deadline to complete it.”

A senior Republican aide told the Examiner that discussions about how to unite members behind an Obamacare reform bill had yielded “no legislative text.”

And Trump himself expressed uncertainty that a new version of the healthcare bill would be ready by next week, although he predicted it could be ready “shortly thereafter.”

“We’re doing very well on healthcare,” Trump said. “We’ll see what happens.”

Premium Increases for Pre-Existing Conditions Under Latest ACA Repeal Plan, by State

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https://www.americanprogress.org/issues/healthcare/news/2017/04/21/431019/premium-increases-pre-existing-conditions-latest-aca-repeal-plan-state/

Hundreds of people march through downtown Los Angeles protesting President Donald Trump's plan to dismantle the Affordable Care Act, March 23, 2017.

Repealing protections for people with pre-existing health conditions could be on Congress’ agenda as early as next week. Facing pressure from the Trump administration, Congress may be ready once again to try to repeal the Affordable Care Act, or ACA. This time around, Congress is discussing including an amendment that would allow insurance companies in the individual market to charge higher rates to consumers based on health status.

Under the deal that was leaked, states would be able to waive protections for pre-existing conditions for any reason, as long as they set up a high-risk pool or participated in a federal risk-sharing program. Before the ACA, all but seven states allowed insurance companies to charge higher premiums to people with pre-existing conditions.

Without pre-existing condition protections, health care would become prohibitively expensive for those who need it most. People with asthma, a relatively minor chronic condition, would face a markup of about $4,000 for coverage, while those with severe illnesses such as heart trouble or cancer would face premiums tens of thousands of dollars above standard rates.

The cost of care varies by state, and health insurance costs do too. The Center for American Progress has estimated the premium surcharges that consumers in each state—and the District of Columbia—would face for five conditions under the new congressional Republican proposal: breast cancer; pregnancy; major depression; diabetes; and asthma. We have also accounted for the federal risk-sharing program that Republicans in Congress have put forward as a means of limiting premium increases. The numbers in the table are the average increases that people currently experiencing the listed conditions would pay on top of the standard rate for health coverage, including the new risk-sharing program.

However, as evidence from before the passage of the ACA shows, insurance companies would also set rates based on previous ailments. More than 130 million nonelderly Americans have pre-existing conditions, and the return of rating on health status would subject them to thousands of dollars of extra expenses for individual market coverage.

Seven states had pre-existing condition protections in place before the ACA: Maine; Massachusetts; New Jersey; New York; Oregon; Vermont; and Washington. We assume that these states would not seek an AHCA waiver to allow rating based on health status and therefore did not calculate health-based surcharges for these states.

 

Trump must decide whether to support or undermine Obamacare

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https://www.washingtonpost.com/powerpost/trump-must-decide-whether-to-support-or-undermine-obamacare/2017/04/19/a52193d6-2502-11e7-bb9d-8cd6118e1409_story.html?_hsenc=p2ANqtz–qRGfjVng2ifif04sBWoB8BnXqWE4AiaOdpPtzmNgoRlaZrrLLv_6KRsxf7m-me-xNmGjvXicczyd7NO4Wdur8XJpBzQ&_hsmi=50970117&utm_campaign=KHN%3A%20First%20Edition&utm_content=50970117&utm_medium=email&utm_source=hs_email&utm_term=.4095c5893438

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President Trump is pressuring Congress to sink parts of the Affordable Care Act. But now that the first attempt at a GOP health-care overhaul has failed, he must decide whether to throw the law a line.

The White House and Republican lawmakers are facing key decisions that could either improve the insurance marketplaces established by the ACA next year or prompt insurers to further hike rates or withdraw from those marketplaces entirely. Republicans had hoped to protect those with marketplace coverage while lawmakers replaced Obamacare.

But with that effort hitting a wall, Trump and his health-care decision-makers are in a bind: They can either let the current system fail and risk raising the ire of 11 million Americans who use the marketplaces, or help stabilize Obamacare and potentially make it harder for Republicans in Congress to abandon the law itself.

“It’s an awkward political environment, there’s no question about it,” said Lanhee Chen, a health-policy expert and former adviser to 2012 presidential candidate Mitt Romney.

Republican objections to the ACA naturally lead them away from assisting it, but the party now bears some responsibility for what happens to it, Chen added.

“The reality of this is Republicans will face some political repercussions for what happens to Obamacare,” he said.

Trump and other Republicans have long predicted a so-called death spiral for the state-based marketplaces set up under President Obama’s signature domestic achievement. Trump has often tweeted and said on the campaign trail that the law will “die of its own weight.” He shrugged off the recent failure of the GOP health-care bill by saying the law is “exploding” anyway.

“The best thing we can do, politically speaking, is let Obamacare explode,” Trump said in the Oval Office last month. “It’s exploding right now.”

The dire predictions have partially come true: Although some state marketplaces offered multiple plan options and only modest premium raises last year, many others provided only one plan choice and double-digit premium hikes. Next year’s outlook is still unclear, but it’s unlikely the marketplaces will suddenly attract a better mix of healthy enrollees to help lower costs.

If the marketplaces further deteriorate, Republicans may take the fall, surveys show. A recent Kaiser Family Foundation poll found that a majority of Americans will now blame Republicans, not Democrats, for marketplace problems, because the GOP spent the past seven years promising to fix and replace the system.

That reality is forcing Republicans, including Trump, to seriously consider a half-dozen actions that could help improve — or at least sustain — the marketplaces where Americans without employer-sponsored plans buy coverage.

“Looking at next year, if we imagine that the marketplace right now is, say, a C-minus, there are several things that need to be done to just preserve it at its C-minus level,” said Mike Adelberg, who under Obama directed the Center for Consumer Information and Insurance Oversight established at the Department of Health and Human Services.

There is a list of actions the administration must decide whether to take to keep the marketplaces humming, most of them through regulatory actions at the Health and Human Services Department or through the Internal Revenue Service.

The actions center on three programs: cost-sharing reductions, reinsurance and risk corridors. Cost-sharing refers to government subsidies to low-income Americans to help them pay for insurance. Trump threatened recently to let such subsidies lapse, but Democrats say they will shut down the government as part of the spending negotiations next week if the president follows through.

Administration officials and lawmakers are still deciding how to handle the issue. A White House spokesman said only that “no decisions have been made at this time.”

Reinsurance and risk corridors are two programs set up under the ACA to redistribute funds from insurers with healthier enrollees to insurers with sicker, more expensive customers.

The marketplaces could also be hurt or helped depending on whether the IRS enforces the ACA’s individual mandate to buy coverage and whether the administration enforces new, tighter rules around enrollment.

The Future Of Delivery System Reform

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http://healthaffairs.org/blog/2017/04/20/the-future-of-delivery-system-reform/

Over the past several years, the federal government has put billions of dollars into a variety of programs aimed at improving the way health care is delivered. The Affordable Care Act (ACA) authorized a broad agenda of reform projects, including accountable care organizations (ACOs), bundled payments, value-based purchasing, primary care initiatives, and other payment and service delivery models. The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 established new ways of paying physicians intended to promote high-quality patient care.

What will happen to these initiatives under a Congress where Republicans are still seeking to enact major new health reforms and a president who could aggressively use authority granted by the ACA to make sweeping changes in Medicare and other health programs? Does this spell the end of delivery system reform, or could this be a new start with a greater potential to promote efficient and effective health care?

The prospect of ACA repeal has raised concerns among advocates, who argue that the enactment of Medicare-led efforts to promote higher-value care represents a real turning point in the battle to reduce waste and inefficiency. They fear that any reversal of the ACA framework would be a setback to the cause of lower costs and higher quality.

Those fears are overblown. There is bipartisan agreement on the goal of promoting more efficient and effective health care. MACRA, which is aimed at improving the value of physician services through payment changes, was enacted on a bipartisan basis. The debate is over the best way to accomplish the goal, not the goal itself.

We agree that it would be unwise to jettison entirely the delivery system reform provisions of the ACA, but their demise would not be the end of efforts to improve US health care. Rather, we see those provisions as far less consequential than their advocates claim, yet they can serve as departure points for putting in place more effective changes that provide room for private initiative and consumer preferences alongside changes in Medicare’s payment systems.

Summing Up

The cost of health care in the United States has grown rapidly for many years, typically well above growth in the overall economy. Those high costs have not guaranteed high-quality care or good patient outcomes, and our delivery system remains inefficient. What is needed is a process of continuous improvement in the efficiency and quality of the care delivered to patients. That is the core belief motivating the delivery system reform effort, which should be continued even as important features of the ACA come under review.

The key question is how best to pursue more cost-effective care delivery in the United States. At the moment, the federal government is trying to use its leverage to bring about greater efficiency, employing its regulatory powers under the Medicare program. That approach, while understandable, should be amended to make room for more private initiative and consumer incentives. Those are the driving forces for productivity improvement in other sectors of the national economy, and they should be harnessed to produce better outcomes in health care as well.