Tag Archives: Health Policy

Push for return to ACA repeal

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https://www.fiercehealthcare.com/aca/repeal-coalition-mcconnell-scalise-hatch-congress?mkt_tok=eyJpIjoiTnpreE9HSTFPVFJqWldZMSIsInQiOiJNM0NTa1ZBZW1kU001bkx4SEcwNmtSeEFVNG9oZnpUbEF2UVpMY1lDUWNZYm8zZTFuejJNUGpPOTJuYVlXTlZwWHdXU1hrRm50Z1NFbHJGRjdUMld6U1JoYWo0enNaUlEzNldab2tcL3hxV3NPaTBlK2xKbmVSQmgwMTE2NFZpYzgifQ%3D%3D&mrkid=959610

Affordable Care Act highlighted

While lawmakers’ most pressing priority right now is to prevent a government shutdown, it’s not too early to start asking: Is the push to repeal the Affordable Care Act over?

The answer to that question, however, depends upon which Republican you ask.

Senate Majority Leader Mitch McConnell has said that while he wants to unwind more of the healthcare law, he’s doubtful that Republicans will have enough votes to do so now that their majority has gotten even slimmer.

But others on the right are pushing to keep the repeal effort alive. Majority Whip Steve Scalise, R-La., said Tuesday that one of the GOP’s major goals this year is to tackle welfare reform, but “then we’re going to have to work on healthcare again.”

“Look, I’m for repealing and replacing Obamacare,” he said during an interview with Fox & Friends, later adding, “So let’s get back to work on some of those things—like what we passed in the House, that almost passed in the Senate—so that we can get our healthcare system working again [and] rebuild the private marketplace.”

The GOP is also facing external pressure. A collection of conservative groups known as the “Repeal Coalition” sent a letter Tuesday to President Donald Trump, saying that now that he’s reformed the tax code, he now must “deliver on the rest of the promises made to the American people to free them from the shackles of Obamacare.”

Thus, the letter said, healthcare reform must be the focus of lawmakers’ budget reconciliation instructions for 2019. The Trump administration must also help the Senate and the House “design a bill that can muster the votes needed for passage of true health reform,” it added.

Whichever path that Republicans choose to take regarding the ACA this year, however, they will do so without a veteran senator who has played a major role in healthcare policymaking. Sen. Orrin Hatch, R-Utah, announced Tuesday that he will not run for an eighth term.

Hatch, who chairs the Senate Finance Committee, has opposed the ACA and criticized a bill drafted by Republican Sen. Lamar Alexander and Democratic Sen. Patty Murray that was designed to stabilize the law. In fact, he floated an alternative to the Alexander-Murray bill that would both temporarily fund cost-sharing reduction payments and ax the individual and employer mandates. Ultimately, he helped repeal the individual mandate via the GOP’s tax reform package.

Hatch also has a history of bipartisanship, however. He was often forced to work with Democratic Sen. Ted Kennedy when they led what is now known as the Health, Education, Labor and Pensions Committee, according to The Salt Lake Tribune. One of their biggest achievements was creating the Children’s Health Insurance Program—though that program is now on shaky ground since Congress let federal funding for it lapse last fall and has since failed to reauthorize it.

 

 

Payer Roundup—Mississippi gets 10-year Medicaid waiver extension; A third of Americans believe ACA is repealed

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Medicaid

CMS approves 10-year Medicaid waiver extension for Mississippi

Last week, the federal government approved its first 10-year extension of a Section 1115 Medicaid demonstration program.

The Mississippi program provides family planning services for people ages 13-44 with income of up to 194% of the federal poverty level. To get approval for its 10-year extension, the state agreed to submit monitoring reports and participate in calls with CMS every year.

The lengthy waiver extension, according to CMS Administrator Seema Verma, lets Mississippi administer its Medicaid program “without the inconvenience of obtaining routine approvals from CMS.” The action also shows the agency’s “continuing commitment to giving states the flexibility they deserve to meet the unique needs of their people,” she said.

Alabama won’t freeze CHIP enrollment or stop coverage—for now

Because of the temporary funding for the Children’s Health Insurance Program included in Congress’ year-end spending bill, Alabama officials canceled their plans to freeze CHIP enrollment on Jan. 1.

The state will also not follow through with its plan to terminate coverage for current CHIP enrollees by Feb. 1, according to AL.com. But Cathy Caldwell, director of the Alabama Bureau of Children’s Health Insurance, told the publication that “we desperately need Congress to act, hopefully in January.”

Federal funding for CHIP expired Sept. 30, and Congress’ effort to reauthorize funding have been bogged down by partisan disputes. The short-term spending bill passed before the holiday break set aside $2.85 billion to temporarily tide states over.

One-third of Americans believe ACA has been repealed

President Donald Trump was not correct when he said that the GOP tax bill repealed the Affordable Care Act, but a new poll indicates a sizable chunk of Americans believe it nonetheless.

According to the poll (PDF), conducted by The Economist/YouGov, 31% of respondents indicated that Trump has delivered on his promise to repeal the healthcare law. Forty-nine percent said that he didn’t, and 21% were unsure.

The sweeping overhaul to the tax code that Republicans passed before the holiday break did repeal the ACA’s individual mandate, a key part of its insurance market reforms. But experts disagree on how big of an impact that will have, and other core components of the law—like premium subsidies—remain intact.

ACA expert to stop blogging for Health Affairs

Timothy Jost, who has chronicled nearly every Affordable Care Act-related development over the past 8½ years, will no longer contribute to the Health Affairs Blog’s “Following the ACA” series.

Jost, a Washington and Lee University professor emeritus, wrote more than 600 blog posts about the adoption and implementation of the healthcare law, plus the omnipresent political battles surrounding it. Jost wrote in his final post that “I am getting older and believe it is time to slow down.” He will continue to write a monthly “Eye on Reform” column for Health Affairs, however.

Katie Keith, a health policy expert with a law degree from Georgetown University and a master of public health from Johns Hopkins University, will take the helm as the author of the Health Affairs blog series on the ACA.

 

From premiums to politics: 5 predictions for the health insurance industry in 2018

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Businessman uses a crystal ball

After the demise of two major insurer mergers and multiple Affordable Care Act repeal attempts, few could argue that 2017 wasn’t an eventful year for the health insurance industry.

But 2018 is shaping up to be just as interesting—complete with more political wrangling, M&A intrigue and evidence that, despite all this uncertainty, insurers are pushing ahead and embracing innovation.

Read on for our predictions about what’s in store for the industry in the coming months.

1. The CVS-Aetna deal will have a domino effect in the healthcare industry

While the lines between payer, provider and pharmacy benefits manager have been blurring for a while now, CVS’ $69 billion deal to purchase Aetna is undoubtedly a game-changer.

The move was likely motivated by a desire to compete with UnitedHealth’s thriving Optum subsidiary, which has its own PBM and an increasing presence in care delivery. So it stands to reason that other major insurers will try to strike deals of their own that mimic that scale and level of diversification.

Already, Humana has made a bid to purchase part of hospice- and home-health giant Kindred Healthcare. There’s also been speculation that it is preparing to be acquired—possibly by Cigna, or in a deal that would mimic CVS-Aetna, Walmart or Walgreens.

Other insurers may also seek to build PBM capabilities, following in the footsteps of UnitedHealth, a combined CVS-Aetna and Anthem, which announced in October that it would team up with CVS to create an in-house PBM called IngenioRx.

It’s certainly possible, however, that CVS’ purchase of Aetna will not pass regulatory muster. While it would require less divestment than the ill-fated Anthem-Cigna and Aetna-Humana deals, the DOJ’s decision to block another vertical deal—between AT&T and Time Warner—doesn’t bode well for its chances.

2. Republicans and Democrats will be forced to work together on ACA fixes

With one less Republican senator—thanks to Alabama’s election of Democrat Doug Jones—the GOP likely won’t have the votes to pass a repeal bill without bipartisan support. Senate Majority Leader Mitch McConnell acknowledged as much before Congress’ holiday recess, though he clarified the next day that he would be happy to pass an ACA repeal bill if there are enough votes for it.

McConnell also owes Sen. Susan Collins, R-Maine, as he had promised her he’d pass her reinsurance bill and a bill that would fund cost-sharing reduction payments this year. While Collins held up her end of the bargain—voting for the GOP tax bill—the ACA fixes didn’t make it into the stopgap spending bill Congress passed on Dec. 21.

Democrats, meanwhile, will also be motivated to reach across the aisle. The repeal of the individual mandate will likely put the ACA on more unstable footing, lending more urgency than ever to the task of shoring up the exchanges.

Both parties will also likely face pressure from the healthcare industry’s biggest lobbying groups to get some sort of ACA fix passed. The push to do so, however, will be complicated by the full slate of legislative priorities Congress is facing in the new year, including reauthorizing funding for the Children’s Health Insurance Program.

3. There will be more premium hikes and insurer exits in the individual market

The individual mandate is now gone, and arguments about its effectiveness aside, that was one of the mechanisms that encouraged healthy people to buy insurance and stay covered. Even if the effect on coverage levels is minimal, the move is probably going to be enough to push risk-averse insurers to raise rates and even exit more rating areas in 2019.

There is also little indication that large insurers that have exited will come back anytime soon. After all, why invest resources in an unstable market when there are far more steady and lucrative markets like Medicare Advantage?

Adding to the policy uncertainty for the remaining insurers, there is no guarantee that Congress will authorize short-term funding for cost-sharing reduction payments. Many insurers raised their 2018 rates to account for the possibility of them disappearing—which turned out to be a wise move—so it stands to reason they’d have to do the same for 2019.

Perhaps the best harbinger of what’s to come came from a study conducted in November, which noted that the actions insurers and state regulators took to fill in “bare counties” on the ACA exchanges are “temporary and unsustainable without long-term federal action.” And with Republicans in charge, federal action to patch up the exchanges is unlikely.

4. Federal agencies will start to carry out Trump’s executive order—and states will push back

Although it was overshadowed by all the repeal-and-replace drama, Trump’s healthcare-focused executive order has huge implications for the industry. Put simply, it paves the way for expanded use of association health plans, short-term health plans and employer-based health reimbursement arrangements.

In 2018, we’re likely to see the relevant agencies start issuing rules to implement the order, which could dramatically change the individual market as we know it—and not for the better. Such rulemaking would also set the stage for a power struggle between the federal government and left-leaning states.

In fact, a coalition of healthcare organizations have urged state insurance commissioners to take steps to override any rules resulting from the executive order. For example, states could restore the three-month limit on short-term health plans if agencies unwind that Obama-era rule on the federal level.

Since only certain states are likely to heed these suggestions, the upshot of Trump’s executive order will be to create a patchwork of individual market rules across the country. If that sounds strangely like what the individual insurance markets were like before the ACA, well, that’s precisely the point.

5. Payers’ move to value-based payment models will continue, with or without the feds leading the way

On the one hand, the Trump administration clearly wants to scale back the federal government’s role in pushing payers and providers away from fee-for-service payment models. The surest sign was CMS’ announcement late last year that it would endmandatory bundled payment models for hip fractures and cardiac care.

Some have worried that moving away from those mandatory programs would be a setback for the move to value-based payments, given that the feds play a powerful role in galvanizing the industry to change. In addition, the administration wants to take the Center for Medicare and Medicaid Innovation in a “new direction”—one that CMS Administrator Seema Verma said would “move away from the assumption that Washington can engineer a more efficient healthcare system from afar.”

But even if the federal government will take a lighter touch in the move from volume to value, it’s not likely that the private sector will take that as a cue to reverse course. On the payer side, especially, too many industry-leading companies have invested heavily in alternative payment models to turn back now. And they have compelling business reasons to keep investing in those models, given their potential to lower costs and improve care quality.

 

Top 10 health care surprises of 2017

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https://www.politico.com/story/2017/12/30/trump-health-care-surprises-248996

Image result for healthcare top stories of 2017

President Donald Trump stormed into office last January confident that he could knock off Obamacare in a nanosecond. It didn’t turn out that way — and from drug prices to the Tom Price travel scandal, a lot of health policy didn’t go according to plan. Here’s a look at 10 health care surprises from 2017.

1. Obamacare survives its seventh year

In control of the White House and both chambers of Congress, Republicans had their best shot ever at Obamacare repeal — and even thought they could have it on Trump’s desk on Inauguration Day. The grand ambitions quickly met roadblocks. Members rebelled over policy details, GOP leaders struggled to find consensus, moderates mutinied, and virtually the entire health care industry — along with Democrats and Obamacare advocates — lined up against every plan that Republicans put forward.

Even so, the GOP eventually squeaked a bill through the House and after several false starts put a proposal on the Senate floor. That’s when Sen. John McCain (R-Ariz.) delivered perhaps the biggest stunner of the year: a late-night thumbs-down that sunk the Senate bill and effectively ended the GOP’s repeal effort … until 2018.

Still, Senate Republicans concede that with an even narrower vote margin, dismantling Obamacare may become, as Sen. Ron Johnson (R-Wis.) delicately put it, “a little more difficult.”

2. Price jets away from HHS

After years of railing against Obamacare as a member of Congress, Tom Price finally got a chance to do something about it as Health and Human Services secretary. The former orthopedic surgeon would aid Republicans’ effort to repeal the law while simultaneously unraveling Obamacare’s web of regulations. He fell short on both counts. Price all but disappeared during the Senate’s bid to craft a repeal bill, frustrating Republicans and, more importantly, the president. Soon after, POLITICO revealed that he had routinely traveled by chartered private or military aircraft, costing taxpayers $1 million.

The scrutiny over his travel habits, combined with Trump’s irritation on Affordable Care Act repeal, sped Price’s resignation seven months into the job. He left few tangible accomplishments — other than the distinction of being the first Cabinet member to make his exit.

3. Tough talk and no action on drug prices

Trump lobbed insults at a host of health care targets, but perhaps none landed with more rhetorical force than his denunciations of the “disastrous” drug industry.

“The drug companies, frankly, are getting away with murder,” he seethed early on, suggesting he might empower Medicare to negotiate with pharmaceutical companies.

It didn’t happen. For all of Trump’s tough talk, he’s made no concrete moves toward cracking down on pharmaceutical prices. A promised executive order never materialized — and a leaked draft of the directive appeared largely pharma-friendly anyway.

In November, Trump nominated Alex Azar, a former pharmaceutical executive, to serve as his next HHS secretary. Azar has already rejected sweeping changes to rein in drug prices, like allowing drug reimportation or giving Medicare greater negotiating power. The administration’s agenda on drug prices now looks smaller, more traditional, and far less of a threat to the pharmaceutical industry.

4. GOP kills the individual mandate — in a tax bill

For all their failures on repealing and replacing Obamacare, Republicans did land a major blow — it just took a tax bill to get the job done. The GOP’s sweeping tax overhaul zeroes out the penalty levied on most people for not purchasing insurance starting in 2019, effectively gutting Obamacare’s individual mandate.

Republicans had long made the mandate a top target for repeal. But it’s also a pillar of the health law — the mechanism that Obamacare supporters contend is crucial to keeping enough healthy people in the market to stabilize premiums.

Yet, in a twist, Senate Republicans who months earlier proved too skittish to dismantle Obamacare jumped at the chance to eliminate the mandate, despite Congressional Budget Office projections that it would drive up premiums 10 percent and leave 13 million more people uninsured over the next decade.

With just 12 days left in a year they’d vowed was Obamacare’s last, Republicans passed their tax bill — and in the process, made their only major legislative change to the health law.

5. Planned Parenthood’s funding goes untouched

The GOP’s sweep into power also placed Republicans on the verge of accomplishing a second top health care goal: defunding Planned Parenthood. Once again, Republicans found themselves foiled by their own members. Moderate Sens. Lisa Murkowski (R-Alaska) and Susan Collins (R-Maine) used their leverage as Senate swing votes to protect the funding of an organization they ardently support.

When McCain joined them in voting down repeal in July, it also put the defunding efforts on hold indefinitely. And now facing only a two-vote advantage in the Senate in 2018, it’s unclear whether the GOP can find the political will to take federal action against Planned Parenthood.

6. The vaccine controversy that never was

When high-profile vaccine skeptic Robert Kennedy Jr. traveled to New York in January to meet with Trump, it looked like the start of a controversial plan to boost the scientifically disproved theory that vaccines can cause autism. Trump had previously suggested vaccines could be dangerous, and Kennedy emerged from Trump Tower touting plans to chair “a commission on vaccine safety and scientific integrity” at the president-elect’s behest.

“President-elect Trump has some doubts about the current vaccine policies and has questions about it,” Kennedy said.

But Trump’s team never confirmed Kennedy’s assertions, and after Inauguration Day any momentum for a vaccine commission appeared to fizzle out. The chiefs of the administration’s Food and Drug Administration, Centers for Disease Control and Prevention and National Institutes of Health all advocate for vaccines, and there hasn’t been a peep from the White House so far about taking any close look at vaccine safety beyond the normal regulatory oversight.

7. Single payer gets serious

At this time last year, single-payer health care was a progressive pipe dream. Now it’s a rallying point for liberal Democrats, a possible litmus test for 2020 hopefuls and a serious policy proposal that’s won the backing of nearly a third of the Senate Democratic Caucus.

Sen. Bernie Sanders’ universal health care plan vaulted into the mainstream in September, after high-profile Democrats trying to strike a contrast to the GOP’s Obamacare repeal efforts latched onto the goal of universal coverage.

“Quality health care shouldn’t be the providence of people’s wealth. It should be a virtue of us being United States citizens,” Sen. Cory Booker (D-N.J.), one of several likely 2020 candidates backing the plan, said at the time.

The single-payer push exposed divisions over how exactly to achieve universal coverage, and several Democrats have put forth their own ideas on how to move more gradually. But the shift in the Democratic platform is clear: Three years after Sanders (I-Vt.) failed to win a single co-sponsor for his plan, universal health care is becoming a defining issue for Democrats in the run-up to 2020.

8. Medicaid as a wedge issue

In a year that was supposed to be all about Obamacare, Congress spent much of its time on Medicaid. The GOP’s Obamacare repeal bills all targeted the low-income health insurance program as well. Their proposals would have profoundly changed the nature of Medicaid — not just the expansion that was part of Obamacare but the traditional parts that predated the ACA by decades.

That’s where the GOP’s health care effort hit perhaps its most intense resistance, as Medicaid — traditionally overshadowed by Medicare — suddenly became a third rail. Democrats seized on projections that capping federal funding would drive deep coverage losses and leave the nation’s most vulnerable worse off. State governors on both sides of the aisle warned that the changes would cripple their ability to deliver crucial services. Swing vote Republicans balked at deep cuts at a time when Medicaid offered the first line of defense against the growing opioid epidemic.

That hasn’t stopped the GOP from taking on Medicaid in other ways. The Trump administration is encouraging states to impose work requirements and has made entitlement and welfare reform — both of which could involve Medicaid — a priority for 2018.

9. Shkreli goes to jail over Hillary’s hair

That Martin Shkreli will finish off this year from prison isn’t a surprise — but it’s what put him there that was unexpected.

The former Turing Pharmaceutical CEO, who gained notoriety for hiking the price of an AIDS drug, was convicted of securities fraud in August. But he was living freely while awaiting sentencing until he offered $5,000 on Facebook for a strand of then-presidential candidate Hillary Clinton’s hair. The post qualified as a “solicitation of assault,” a judge ruled, before revoking Shkreli’s bond and sending him to prison.

It’s just one of many strange twists in Shkreli’s saga, which included calling congressmen “imbeciles” on Twitter hours after refusing to answer questions at a House committee hearing; livestreaming on YouTube for hours on end, including right after his conviction; and purchasing the sole copy of a 2015 Wu-Tang Clan album for more than $1 million. He’ll now serve jail time over his request for Clinton’s hair until a mid-January sentencing hearing.

10. Collins, Murkowski play power brokers in the Senate

The most moderate members in a Republican Conference that narrowly controls the Senate, Collins and Murkowski were always going to be crucial players. But GOP leaders may not have anticipated just how much they’d flex that power.

Collins and Murkowski held out throughout the repeal effort over Medicaid cuts and skimpier subsidies they worried would hurt their states — and tanked a top GOP priority. At the end of the day, both voted for the big tax bill, with its individual mandate repeal. Collins got a promise from Senate leaders that two ACA stabilization bills would be included in Congress’ year-end spending agreement — though the bill have been pushed into 2018 and are in trouble, given the House opposition.

With Republicans’ margin in the Senate set to narrow to just 51-49 next year, Collins and Murkowski appear set to exercise even more influence over the party’s direction come 2018.

 

3 political issues for hospitals to watch in 2018

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3 political issues for hospitals to watch in 2018

Hospitals and health providers suffered minimal damage in this year’s political collision over Obamacare. But 2018 will bring a series of equally high-stakes debates that will affect the financial viability of hospitals and the future of how care is measured and delivered.

And by the way, the war over Obamacare is hardly over — it’ll start up again next year with proposals to stabilize insurance markets and renewed GOP repeal efforts.

Here are some additional issues to watch:

Redefining value

The Trump administration is promising to set a new course for medicine’s value movement. Seema Verma, the chief of Medicare and Medicaid, is evaluating proposals for ways to link government reimbursement to patient outcomes. She is moving away from the mandatory payment programs created under President Obama — in which hospitals received lump sum payments for repairing fractured hips and other services — in favor of voluntary models with more flexible arrangements created by doctors and hospitals.

Greater leeway from the federal government might make it easier for hospitals to experiment with novel ideas, like pushing for new payment arrangements in specialty areas such as gastroenterology, behavioral health, and cancer care. But the additional flexibility could also take the teeth out of reforms and fatten providers’ margins without delivering corresponding cost and quality benefits.

It is unclear when the Trump administration will unveil its plans for new payment programs, but keep an eye out for news in the first half of 2018.

Medicaid, Medicaid, Medicaid

The federal program that provides care for the poor and disabled will remain a Republican target next year. The prospects of sweeping federal legislation appear dim, with strong Democratic opposition against a razor-thin GOP majority in the Senate. But the Trump administration may cut the program anyway, by giving states more flexibility to reshape their programs. That could mean swift approvals of popular GOP reforms, such as work requirements and premium-like payments by beneficiaries.

The implications couldn’t be bigger for providers, or their low-income patients. The underlying goal of these efforts is to reduce enrollments in the $500 billion program, an outcome that would increase uncompensated care and financial instability for struggling hospitals and households. But Republicans argue that cuts are necessary to keep federal spending in check and free states from mandates that are crowding out other budget priorities. That clash of interests will generate skirmishes across the country in 2018.

FDA regulation of medical technology

The Food and Drug Administration is redefining what it means to be a medical device in the digital age — a process that will have implications for the health care facilities that are the primary purchasers of such devices.

The FDA recently proposed streamlining the regulation of many health software products. The move will broaden providers’ arsenal of digital tools, such as decision support programs that helps doctors detect and respond to infections or diagnose rare diseases.

However the agency did not take a firm position on machines that rely on artificial intelligence, an area poised to generate plenty of debate in coming months. Products like Watson, IBM’s supercomputer, still fall in a regulatory gray area, as do others that rely on algorithms whose inner workings are shielded from users.

The key question is this: Should the FDA require companies to prove their products deliver safe and effective advice, or can they unleash these machines in health care with minimal oversight?

 

The uninsured are overusing emergency rooms — and other health-care myths

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https://www.washingtonpost.com/news/wonk/wp/2017/12/27/the-uninsured-are-overusing-emergency-rooms-and-other-health-care-myths/?utm_term=.98d00c3511a6

In the search for ways to bring down American health-care spending, there are certain ideas that are close to dogma. Chief among them: If you provide health insurance to people, they will stop overusing the emergency room.

“A lot of people just didn’t bother getting health insurance at all. And when they got sick, they’d have to go to the emergency room,” President Obama said in a 2016 speech. “But the emergency room is the most expensive place to get care. And because you weren’t insured, the hospital would have to give you the care free, and they would have to then make up for those costs by charging everybody else more money.”

The idea that uninsured people are clogging emergency rooms looks more and more like a myth, according to a recent study published in Health Affairs. Uninsured adults used the emergency room at very similar rates to people with insurance — and much less than people on Medicaid. Providing insurance to people can have many benefits, but driving down emergency room utilization doesn’t appear to be one of them.

 

Medicaid is GOP target in 2018

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http://thehill.com/policy/healthcare/366728-gop-could-push-medicaid-cuts-in-2018

Image result for medicaid target

Medicaid could face crucial tests in 2018 at both the federal and state levels.

Republicans in Congress failed in their attempts earlier this year to impose drastic cuts to the program as part of ObamaCare repeal, but GOP lawmakers could try again next year.

The tax bill that President Trump recently signed into law is projected to add $1 trillion to the federal deficit, making cuts to Medicaid an even more tempting target for some conservatives.

“Medicaid is front and center in any budget exercises, and now that deficits have increased, it puts Medicaid squarely in the bull’s-eye,” said Joan Alker, the executive director of the Georgetown University Center for Children and Families.

Speaker Paul Ryan (R-Wis.) has said he wants to bring down entitlement spending, saying in December that “health-care entitlements such as Medicare and Medicaid are the big drivers of debt.”

Any entitlement cuts from Ryan will likely face pushback from members of his own party, including Senate Majority Leader Mitch McConnell (R-Ky.). McConnell has said he doesn’t expect to see entitlement reform on the agenda next year ahead of the midterms.

“The sensitivity of entitlements is such that you almost have to have a bipartisan agreement in order to achieve a result,” McConnell told reporters in late December.

Medicaid covers nearly 75 million people, and the program has proven resilient in the face of conservative opposition.

Cindy Mann, a consultant at Manatt Health who ran Medicaid under former President Obama, said attacks on Medicaid have made it more popular.

“Medicaid has always been supported by the people closest to it,” Mann said.

Some Republican senators have recognized the political risks of Medicaid cuts, too. The GOP’s ObamaCare repeal push failed in part because of senators opposed to the Medicaid cuts.

“The Medicaid program is starting to get a politically powerful status,” said Eliot Fishman, the senior director of health policy at Families USA, an advocacy group.

Fishman noted that Maine, Arizona and Alaska are all Medicaid expansion states represented by Republican senators who have shown a willingness to protect the expansion funding.

Over 16 million people have enrolled in Medicaid since states began expanding coverage under ObamaCare. The program could continue to grow in the near future, as more states could seek to take advantage of the additional federal money offered by the health law.

Future Medicaid expansions could be especially likely if a Democratic wave in November’s midterms gives Democrats control in more statehouses.

In Virginia, Gov.-elect Ralph Northam (D) has promised to expand Medicaid, something Democrats in the state have been unable to accomplish in the last four years in the face of a GOP-controlled legislature. But with a 50-50 split in the House or even a 51-49 Democratic minority, depending on the results of a recount, Northam has much better odds than current Gov. Terry McAuliffe (D).

In Maine, voters approved a ballot initiative allowing the state to expand Medicaid. Gov. Paul LePage (R) has refused to implement it, but a new governor replacing LePage after he leaves office in the face of term limits could be more willing to accept the results.

If even a few more states choose to expand Medicaid, “it starts to get to be enough critical mass nationwide that I would hope it just makes it a permanent part of the Medicaid program,” Fishman said.

But advocates worry that unprecedented flexibilities offered by the Trump administration will allow states to completely change the nature of Medicaid.

Administration officials have said they will allow governors to add work requirements, time limits and lockout periods for people who can’t pay their premiums on time.

Advocates say adding such provisions would further the Republican case that Medicaid is a welfare program, instead of health insurance.

“Whether you support them or not, those activities are not the function of a Medicaid program,” Mann said. “People can differ as to the efficacy of those efforts, but few people can accurately say that’s what health insurance ought to be doing.”

In the coming months, the Trump administration could approve waivers allowing states like Arkansas, Arizona, Indiana and Kentucky to impose work requirements on Medicaid beneficiaries.

Arizona also wants to impose a five-year limit on Medicaid eligibility for the “able-bodied.”

States that want work requirements have acknowledged that tens or even hundreds of thousands of people would lose Medicaid coverage under the proposals.

Prior to ObamaCare, Medicaid mainly covered children, the disabled and pregnant women. The law’s optional expansion allowed many more low-income people to become eligible, leading to criticisms from conservatives that “able-bodied” beneficiaries were essentially freeloading off the government.

Alker said that’s the wrong way to look at it.

“[Medicaid is] predominantly run by managed care insurance companies, so that kind of rhetoric is a gross oversimplification,” Alker said. “But people who want to cut it, they tend to focus on one population.”

The Leap to Single-Payer: What Taiwan Can Teach

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The Leap to Single-Payer: What Taiwan Can Teach

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Taiwan is proof that a country can make a swift and huge change to its health care system, even in the modern day.

The United States, in part because of political stalemate, in part because it has been hemmed in by its history, has been unable to be as bold.

Singapore, which we wrote about in October, tinkers with its health care system all the time. Taiwan, in contrast, revamped its top to bottom.

Less than 25 years ago, Taiwan had a patchwork system that included insurance provided for those who worked privately or for the government, or for trade associations involving farmers or fishermen. Out-of-pocket payments were high, and physicians practiced independently. In March 1995, all that changed.

After talking to experts from all over the world, Taiwan chose William Hsiao, a professor of economics at the Harvard T.H. Chan School of Public Health, to lead a task force to design a new system. Uwe Reinhardt, a longtime Princeton professor, also contributed significantly to the effort. (Mr. Reinhardt, who died last month, was a panelist on an Upshot article comparing international health systems in a tournament format.) The task force studied countries like the United States, Britain, France, Canada, Germany and Japan.

In the end, Taiwan chose to adopt a single-payer system like that found in Medicare or in Canada, not a government-run system like Britain’s. At first, things did not go as well as hoped. Although the country had been planning the change for years, it occurred quite quickly after democracy was established in the early 1990s. The system, including providers and hospitals, was caught somewhat off guard, and many felt that they had not been adequately prepared. The public, however, was much happier about the change.

Today, most hospitals in Taiwan remain privately owned, mostly nonprofit. Most physicians are still either salaried or self-employed in practices.

The health insurance Taiwan provides is comprehensive. Both inpatient and outpatient care are covered, as well as dental care, over-the-counter drugs and traditional Chinese medicine. It’s much more thorough than Medicare is in the United States.

Access is also quite impressive. Patients can choose from pretty much any provider or therapy. Wait times are short, and patients can go straight to specialty care without a referral.

Premiums are paid for by the government, employers and employees. The share paid by each depends on income, with the poor paying a much smaller percentage than the wealthy.

Taiwan’s cost of health care rose faster than inflation, as it has in other countries. In 2001, co-payments for care were increased, and in 2002, they went up again, along with premiums. In those years, the government also began to reduce reimbursement to providers after a “reasonable” number of patients was seen. It also began to pay less for drugs. Finally, it began to institute global budgets — caps on the total amount paid for all care — in the hope of squeezing providers into becoming more efficient.

Relative to the United States and some other countries, Taiwan devotes less of its economy to health care. In the early 2000s, it was spending 5.4 percent of G.D.P., and by 2014 that number had risen to 6.2 percent. By comparison, countries in the Organization for Economic Cooperation and Development spend on average more than 9 percent of G.D.P. on health care, and the United States spends about twice that.

After the most recent premium increase in 2010 (only the second in Taiwan’s history), the system began to run surpluses.

This is not to say the system is perfect. Taiwan has a growing physician shortage, and physicians complain about being paid too little to work too hard (although doctors in nearly every system complain about that). Taiwan has an aging population and a low birthrate, which will push the total costs of care upward with a smaller base from which to collect tax revenue.

Taiwan has done a great job at treating many communicable diseases, but more chronic conditions are on the rise. These include cancer and cardiovascular and cerebrovascular disease, all of which are expensive to treat.

The health system’s quality could also be better. Although O.E.C.D. data aren’t available for the usual comparisons, Taiwan’s internal data show that it has a lot of room for improvement, especially relating to cancer and many aspects of primary care. Taiwan could, perhaps, fix some of this by spending more.

As we showed in our battle of the health care systems, though, complaints can be made about every system, and the one in the United States is certainly no exception. For a country that spends relatively little on health care, Taiwan is accomplishing quite a lot.

Comparing Taiwan and the United States may appear to be like comparing apples and aardvarks. One is geographically small, with only 23 million citizens, while the other is vast and home to well above 300 million. But Taiwan is larger than most states, and a number of states — including Vermont, Colorado and California — have made pushes for single-payer systems in the last few years. These have not succeeded, however, perhaps because there is less tolerance for disruption in the United States than the Taiwanese were willing to accept.

Regardless of which health system you might prefer, Taiwan’s ambition showed what’s possible. It took five years of planning and two years of legislative efforts to accomplish its transformation. That’s less time than the United States has spent fighting over the Affordable Care Act, with much less to show for it.

 

Five key decisions for the GOP on healthcare

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http://thehill.com/policy/healthcare/366528-five-key-decisions-for-the-gop-on-healthcare

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Republicans have repealed ObamaCare’s individual mandate, but they still have a number of decisions to make on health care in the coming year.

Even without the unpopular mandate, the health care law is still largely in effect, with nearly 9 million people enrolled in private plans for 2018.

And beyond ObamaCare, Republicans could seek action on entitlement reform and drug pricing in 2018.

Here are five things to watch out for.

Will Republicans try again to repeal ObamaCare? 

After Republicans failed to act on a seven-year promise to repeal and replace ObamaCare, they assured voters they would return to the issue after passing tax reform.

But now that the tax law is on the books, it’s far from certain that Republicans will make another run at the Affordable Care Act. With the GOP’s Senate majority set to shrink in January, repeal might be off the table for now.

“Well, we obviously were unable to completely repeal and replace with a 52-48 Senate,” Senate Majority Leader Mitch McConnell told NPR on Thursday.

“We’ll have to take a look at what that looks like with a 51-49 Senate. But I think we’ll probably move on to other issues.”

But McConnell could face pressure from more conservative Senate Republicans — and possibly from the House — to revisit health care, no matter how steep the challenge.

“To those who believe — including Senate Republican leadership — that in 2018 there will not be another effort to Repeal and Replace Obamacare — well you are sadly mistaken,” Sen. Lindsay Graham (R-S.C.), author of the most recent repeal bill, tweeted last week.

Will Congress act to stabilize ObamaCare? 

Sens. Susan Collins (R-Maine) and Lamar Alexander (R-Tenn.) have been pushing for a vote on two bipartisan bills to stabilize ObamaCare’s insurance markets, but those efforts were pushed off until next year.

McConnell assured Collins the bills would be attached to a “must-pass” bill by the end of 2017, but that changed as Republicans scrambled to avoid a government shutdown.

Now Senate Republicans are looking to attach the ObamaCare bills to the long-term spending bill that is expected to come up for a vote in January.

But passing the ObamaCare bills is far from certain, with House Republicans demanding the inclusion of Hyde Amendment language to prevent any federal money from going to plans that cover abortions.

House Republicans have also been critical of the overall substance of the bills, arguing they’re a “bail out” of a failing law.

It’s unclear whether House Republicans would support a spending bill that contains the ObamaCare bills, but many have said they definitely won’t if the abortion language isn’t included.

Sen. Mike Rounds (R-S.C.) said Senate Republicans are looking at ways to resolve the issue, and Alexander said he’s optimistic about the bills passing in January.

“We have the president’s renewed interest, more interest from the House, Senate McConnell has renewed his commitment to schedule it and support it, so I think it’s just a matter of when we come back, putting out ideas together and finding a way to get it done,” Alexander told reporters.

Will Republicans try to tackle entitlements?

Speaker Paul Ryan (R-Wis.) has said Republicans should move to entitlement reform next year, citing the need to address the nation’s red ink.

“We’re going to have to get back next year at entitlement reform, which is how you tackle the debt and the deficit,” Ryan told the Ross Kaminsky radio talk show earlier this month.

While there’s broad support in the GOP for taking up welfare reform, changes to entitlement programs like Medicare and Social Security could be a tough sell.

McConnell has noted that a slim Republican majority in the Senate could put broader entitlement reform out of reach.

“The sensitivity of entitlements is such that you almost have to have a bipartisan agreement in order to achieve a result,” McConnell said at a press conference Friday.

“The only time we’ve been able to do that is on a bipartisan basis, and it was a long time ago.”

Entitlement cuts could also be politically dangerous for Republicans leading into the 2018 midterms.

Will Trump try to help ObamaCare? 

Democrats have accused the Trump administration of trying to sabotage ObamaCare by slashing the law’s advertising and outreach budget and cutting open enrollment in half.

But those actions seemed to have a minimal effect on enrollment. The administration said 8.8 million people signed up for coverage in the exchanges this year, which is only a slight drop from the 9.2 million people who signed up last year.

Democrats say these numbers show the resiliency of the law.

“[The] enrollment numbers make clear that the American people want access to high quality, affordable health insurance coverage, and they want Congress and the Administration to stop playing games with our health care system,” said Rep. Frank Pallone (D-N.Y.), ranking member of the House Energy & Commerce Committee.

Trump indicated on Tuesday that his administration still intends on repealing and replacing ObamaCare, however.

“Based on the fact that the very unfair and unpopular individual mandate has been terminated as part of our tax cut bill, which essentially repeals (over time) ObamaCare, the Democrats & Republicans will eventually come together and develop a great new HealthCare plan!”

Will Trump take action on drug prices? 

Trump came out swinging against drug companies when he took office in January, declaring that the industry is getting away with murder, but so far has taken little action on drug prices.

The administration has been preparing an executive order aimed at lowering drug prices since the summer, but critics argue the order would be friendly to drug companies.

Trump has also abandoned campaign promises to allow Medicare to negotiate drug prices and expand importation of cheaper drugs from other countries.

However, Alex Azar, a former drug executive and Trump’s nominee to lead the Department of Health and Human Services, has said that addressing h drug prices will be one of his top priorities if he’s confirmed.

“I believe I can hit the ground running to work with you and others to identify solutions here,” Azar told senators during his confirmation hearing.

 

10 things for healthcare executives to note as they head into 2018

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https://www.beckershospitalreview.com/hospital-management-administration/2017-the-year-that-was-10-things-for-healthcare-executives-to-note-as-they-head-into-2018.html

Disruption got real. Hospital-insurer negotiations heated up. Activist shareholders shook up legacy hospital operators. Healthcare and the government failed to effectively communicate. These and six other trends that shaped the year in healthcare — and the lessons executives can take from them into 2018.

1. Disruption got real. After years of speculation about who or what would become the “Uber of healthcare,” the tectonic plates of the industry shifted substantially in the past year — and there’s reason to believe this will only continue in 2018. A number of mergers illustrate the blurring line between healthcare and other industries, such as retail and insurance. Consider the combinations of CVS and Aetna or Optum and DaVita and Surgical Care Affiliates. As for what’s to come, Apple and Amazon have both shown interest in expanding their healthcare footprint. In fact, just last month, we reported Amazon was in talks to move into the EHR space.

Executive’s takeaway: Executives grew skeptical of the term ‘disruptor’ when it was used as generously as it was circa 2011-2016. But now disruption is actually unfolding at a rapid clip, and executives are paying close attention to who/what poses the greatest threat to their business models.

2. Hospital-insurer negotiations heated up. Previously, a health system and a commercial insurer occasionally hit a snag in the contract negotiation process, resulting in a dispute palpable enough to consumers that it warranted headlines. These impasses generally lasted a matter of weeks before outside pressure drove the parties to compromise. The nature of these conflicts has since changed. This past year brought regular coverage of strained provider-payer talks. In fact, we now do a weekly compilation of payer-provider disputes and resolutions to stay abreast of these conflicts as they occur and subside. In 2017, we saw lawmakers intervene in payer-provider disputes, a health system executive’s meant-to-be-private email about an insurance company go public, and a children’s hospital go out of network with a commercial insurer — affecting 10,000 kids.

Executive’s takeaway: Health system executives are growing increasingly vocal with their thoughts about commercial insurers. In the past, executives took great lengths to observe discretion in these relationships. Now the gloves are off — or at least one is. We’re sure we haven’t seen the worst of a payer-provider dispute yet, but the number we see on a weekly basis, and their tone, indicates that disputes are both more frequent and more serious than in years past.

3. Investments in value-based care, once a somewhat safe bet, became debatable. In a final rule issued in November, CMS officially canceled the hip fracture and cardiac bundled payment programs and rolled back some mandatory requirements in the Comprehensive Care for Joint Replacement Model. This will continue to have a ripple effect on payers, providers and health system strategy. For hospitals and health systems that made significant investments to support excellence under the program, this news is difficult to take — especially since no investment is made lightly amid thin margins. Although CMS says it is still committed to value-based care as a concept, the mandatory nature of the bundles program acted as a pedal-to-the-metal force that made hospitals act. Since commercial payers follow Medicare, the fate of the program will likely influence the adoption of bundles among private insurers, too. 

Executive’s takeaway: Most all executives tell us they want to be on the leading edge, not bleeding edge, of value-based care. Without a “do it or lose it” approach to bundles, the industry lost a major impetus toward value-based care, in which many health systems and physicians would take the plunge together. Providers have never had a clearly paved path for their “journey toward value-based care.” At best, it was a dirt trail. Now it could be compared to a dirt trail covered in snow. This leaves executives questioning the value of their current and future investments in value-based care.

4. Big systems want bigger. Just when you thought you had a handle on what a “big” health system looked like in the United States, a few major players rewrote (or are attemping to rewrite) the playbook. After more than a year of talks, Catholic Health Initiatives and Dignity Health signed a definitive agreement in December to create a 139-hospital, $28.4 billion health system. Soon after came reports of St. Louis-based Ascension and Renton, Wash.-based Providence St. Joseph discussing a merger, which would result in a 191-hospital, $44.8 billion operation. Although both of these deals trail Oakland, Calif.-based Kaiser Permanente and its nearly $65 billion in revenue, they illustrate how the composition of nonprofit American health systems is continuing to change from local and regional entities to corporate national networks. For example, if Ascension and Providence combine, they will outsize the largest for-profit health system today — Nashville, Tenn.-based HCA Healthcare — which includes 177 hospitals in 20 states and Britain.

Executive’s takeaway: Executives may want to reevaluate the oft-spoken phrase “all healthcare is local” in light of 2017’s M&A activity. Hospitals will continue to serve as economic engines in their respective communities, but the organization of health systems is moving in a direction where they are viewed as ubiquitous brands as opposed to regional hubs for health. For example, San Francisco-based Dignity and Englewood, Colo.-based CHI are basing the corporate headquarters for their new enterprise in Chicago. Ascension and Providence would have footprints in 27 states if they merge.

5. Many health systems that were new players in the health plan business got out of it. Provider-sponsored health plans always carried a great amount of risk. Of the 37 health plans launched by hospitals and health systems since 2010, only four were found profitable in 2015, according to research published this past year by the Robert Wood Johnson Foundation. As major health insurers reduced their individual coverage options and rolled back from the public exchanges this year, we also saw several health systems decide to scale back or shut down their health plans. New Hyde Park, N.Y.-based Northwell Health shared plans in August to wind down its health insurance business, CareConnect, over the next year. Dayton, Ohio-based Premier Health is selling its health plan to Evolent Health, a Washington, D.C.-based value-based care platform. Louisville, Ky.-based Baptist Health plans to shut down its health plan operation in 2018. Late last year, Dallas-based Tenet Healthcare revealed plans to scale back its insurance business in 2017 after officials attributed lukewarm earnings to its health plan business.

Executive’s takeaway: When even the big five health insurers — so well-equipped with analytic tools, data, infrastructure, utilization management experience and risk analysis talent — have a difficult time accounting for risk, it is not surprising many green health systems made their move for the door this past year. This is not an opportune time for health systems with little experience managing risk to build or buy a health plan. 

6. Activist shareholders shook up legacy hospital operators. Board room issues within the major for-profit hospital operators are typically opaque, but 2017 brought a rash of investor-prompted activity that resulted in ousted CEOs, overhauled boards of directors, poison pills and new governance rules. Tenet Healthcare underwent significant change in 2017 under intense pressure from its largest shareholder, Glenview Capital Management. When two Tenet board members, both employed by Glenview, resigned over what they described as “irreconcilable differences,” they made it known that Glenview would possibly “evaluate other avenues” to be a constructive owner of Tenet on or after Sept. 1. By Aug. 31, Tenet announced it would replace CEO Trevor Fetter, “refresh” the composition of its board of directors and implement a short-term shareholder rights plan. Mr. Fetter resigned in October, before a successor was named, after 14 years with the system. In August, an investor in Franklin, Tenn.-based Community Health Systems called for the resignationof CEO Wayne Smith, who has led the 127-hospital system since 1997, over what the investor described as missteps in strategy resulting in financial trouble for the system. At this time, Mr. Smith still holds his job, but CHS may be bracing for more investor activity. Chinese billionaire Tianqiao Chen has gradually been ramping up his stock in the hospital operator since 2016. At time of publication, he holds nearly 23 percent of CHS stock. Finally, directors of HCA Healthcare made a change in late 2017 to allow established investors to participate in the board seat nomination process, a move made in response to an activist investor.

Executive’s takeaway: The fact that two of the largest U.S. for-profit hospital operators faced calls for CEO resignations in 2017 is part of a sweeping trend across industries in which activist investors start campaigns for change by targeting top management. Between January and May 2017, activist shareholders were responsible for ousting CEOs at three high-profile S&P 500 companies — American International Group, CSX and Arconic, according to The Wall Street Journal. Investors were attempting to oust six other CEOs in the same time frame. It’s worth noting that CEOs feel the heat at the launch of campaigns versus as a last resort. The WSJ characterized this trend as “a new level of aggressiveness for a group already known for its bold actions.” 

7. As the average health system C-suite grew, a few systems reduced administrative roles. While the number of practicing physicians in the U.S. grew 150 percent between 1975 and 2010, the number of healthcare administrators increased 3,200 percent in the same period. Yet in 2017, we saw a few major health systems go against the grain and not only lay off administrators, but eliminate their roles completely. In June, Houston-based MD Anderson Cancer Center eliminated executive vice president roles and gave senior vice presidents more focused areas of responsibility. Valley Medical Center, part of Seattle-based UW Medicine, got rid of the COO position in May, and Charleston, S.C.-based Roper St. Francis did the same in August. In December, San Diego-based Scripps Health shared plans to eliminate the CEO position in its four hospitals in favor of a regional CEO model. 

Executive’s takeaway: This past year contained several isolated incidents in which executive or administrative jobs were not immune from the financial pressures mounting on hospitals and health systems. There is reason to believe “right-sizing” (or at least reducing) administrative staffing at health systems will continue throughout 2018. Chris Van Gorder, president and CEO of Scripps Health, recently shared that layoffs at the system will likely include administrative and leadership roles while the system continues to hire caregivers. His reasoning, an excerpt of which follows, is applicable to many health systems today: “Healthcare is changing rapidly with huge growth in ambulatory care and reduced utilization of inpatient hospitals — and given the elimination of the individual mandate under the Affordable Care Act, the uninsured will once again be growing nationally. … We’ve got to shift our organizational structures around to be able to deal with the new world of healthcare delivery, find ways of lowering our costs significantly. If we don’t, we will not be able to compete.”

8. Healthcare and the government failed to effectively communicate. In 2017, the opportunities for the Trump administration, Congress and healthcare leaders to convene about healthcare legislation and policy came and went. CEOs from the five largest nonprofit health systems in the country took pen to paper, urging President Donald Trump and Congress to meet with them and exchange ideas. In the end, the closest thing we saw to healthcare reform in 2017 were bills — the American Health Care Act, Better Care Reconciliation Act of 2017 (or Skinny Repeal package), the Graham-Cassidy healthcare bill — that received significant opposition from major healthcare stakeholders, which are not historically liberal. Yet even an avalanche of nays from the American Medical Association, American Hospital Association, Federation of American Hospitals, American Psychiatric Association, Association of American Medical Colleges and several other groups did not sway Congress. All but three Republican Senators voted to pass the Skinny Repeal package, illustrating how the bipartisan nature of our political process is overriding expertise and informed lawmaking. 

Executive’s takeaway: A bipartisan approach is the most effective way when attempting to redesign a $3 trillion industry that influences life-or-death decisions. These efforts also require input from a variety of seasoned healthcare experts who can challenge ideas, anticipate repercussions and identify blind spots. This holds true no matter which party holds control of the White House, Congress or both. Although healthcare stakeholders and government officials did not productively connect in 2017, health system leaders must persist in their attempts to influence public policy and exercise greater creativity in their advocacy efforts. Strategies that worked in the past can no longer be counted on in 2018 and beyond. 

9. Fed up, nurses walked off the job. While nurses’ strikes are not a novel event, there is a reason many demanded wider attention and transcended local business news to become national headlines. The most noteworthy strike of the year took place July 12, when approximately 1,200 nurses at Boston-based Tufts Medical Center began a 24-hour strike — the first nursing strike Boston saw in 31 years. Roughly 120 miles from Boston, approximately 800 nurses at Berkshire Medical Center in Pittsfield, Mass., participated in a one-day strike in October. Across the country in California, nurses organized rallies and protests at more than 20 Kaiser Permanente sites to protest what they called inadequate staffing levels. In September, nurses and other hospital personnel unionized with SEIU walked off their jobs at Riverside University Health System – Medical Center in Moreno Valley, Calif., for three days. The county footed the $1.5 million bill for temporary replacement nurses for those 72 hours. Speaking of a bill, Minneapolis-based Allina Health tallied the costs of two 2016 strikes — one lasting six weeks — called by the Minnesota Nurses Association. The system put the figure in the ballpark of $149 million, which anchored Allina’s operating loss of $30 million for fiscal year 2016. 

Executive’s takeaway:  Although it is tempting to reduce labor strikes to events fueled by local market forces and politics, hospital and health system executives should pause and consider that striking nurses’ arguments — that they are expected to work demanding jobs with too few staff, resulting in unsafe conditions, high stress and burnout — is a description that applies to many, if not most, U.S. hospitals. Gender dynamics may also yield greater influence on administrator-nurse affairs in the coming year. As the nation comes to terms with troubling events that went unaddressed after women’s claims and voices were not met with the attention they deserved, health system executive teams are wise to change the approach taken in years past and pay closer attention to the female-dominated field of nursing. As one representative with the MNA told The Nation: “[Management is] a male institution thinking they can snub 1,200 women and pretend their opinions about healthcare don’t count.”

10. The year healthcare became very, extremely, incredibly difficult. Was any component of healthcare ever easy? Those who have spent years in the industry would say no. Yet 2017 was the year in which officials and lawmakers reminded the American public that healthcare is complicated. While true, this narrative functioned as a sound bite to normalize Congressional dysfunction. 

Executive’s takeaway: What’s concerning here is whether this throwaway statement will make its way from Capitol Hill to hospital board rooms, executive offices, clinician lounges and medical school lecture halls and, over time, nurture a climate that fosters and condones inaction. It is unproductive to constantly point out the complicated nature of healthcare and/or bask in this acknowledgement. To do so is not the behavior of an effective leader. It goes without saying that healthcare is complicated. Healthcare is also necessary, expensive, life-saving, honorable, slow, inaccessible, urgent, flawed, and never going away. What are you doing to make it better?