A happy health care year in 2018 would be the reverse image of 2017, considering that the past 12 months have mostly been about Congress relitigating the Affordable Care Act (ACA) while failing to do the most basic things to keep successful health care programs going.
Think about the issues that dominated the past year, such as the vote-after-vote effort to repeal and replace the ACA. While full repeal did not happen, legislation to weaken the law, combined with the Trump administration's efforts to undermine implementation, threatened to slow or reverse the historic gains in coverage that have occurred since the ACA became law almost a decade ago.
Meanwhile, Congress' failure to reauthorize the Children's Health Insurance Program (CHIP) in a timely manner (federal funding for the program ended on Oct. 1, 2017, and at the time this column went to press in December, Congress had yet to reauthorize it) caused states to begin sending out warnings to families advising them that their kids' coverage may soon be terminated. Funding for community health centers and the National Health Services Corps, which also expired on Oct. 1, was also in jeopardy because of Congress' inaction. Even on issues that on paper have strong bipartisan support, like programs to prevent and mitigate the terrible toll of opioid abuse, disagreements over how much money to put into them have stalled progress in countering the epidemic.
So no, we don't want 2018 to be anything like 2017. But lawmakers, Republicans and Democrats alike, and President Trump have an opportunity to turn the page this year and work together on real solutions to the real problems in the American health care system. Here is my list of where they should start.
1. Expand access to affordable and adequate health insurance coverage rather than trying to take it away.
Republicans should acknowledge that the ACA is here to stay, and Democrats should acknowledge that the ACA must be improved to make coverage affordable for millions who remain priced out of it. Lawmakers should pass bipartisan legislation to create a reinsurance fund for insurers to offset the added cost to them if they end up having too few healthy enrollees to subsidize the costs of treating sicker ones; offer a publicly funded coverage option in all insurance markets; continue cost-sharing reduction payments to insurers; and give states more flexibility to design their own coverage models, provided that they cover as many people with comparable benefits and protections as the ACA.
2. Lower the cost of health care, starting with pharmaceutical prices.
We pay more for health care in the United States mainly because our prices are higher, whether it's for advanced imaging, hospital stays, emergency care, nonprimary care physician services, or prescription drugs. Polls show that overwhelming majorities of voters, whether Republicans, Democrats, or independents, want Congress to address the problem of excessive drug prices, so this would be a good place to start. Congress should look to the Campaign for Sustainable Rx Pricing, of which ACP is a member, for ideas on how to lower drug prices through greater competition and transparency and should also give Medicare the authority to directly negotiate prescription prices with manufacturers.
3. Reduce the crushing administrative burden on doctors and patients.
The United States is facing an epidemic of physician burnout, much of it due to the excessive paperwork and electronic health record documentation requirements imposed on doctors. Unnecessary administrative tasks also take doctors' time away from their patients, leading to harried visits that are unfulfilling for both the patient and the doctor. We also spend far more on insurance company interactions and other administrative tasks than most other countries do.
Several months ago, CMS Administrator Seema Verma announced the agency's Patients Over Paperwork initiative, which appears to be modeled on ACP's own two-year-old Patients Before Paperwork advocacy campaign. A key congressional subcommittee also held hearings on the same subject. Now is the time for Congress and the administration to deliver real changes to reduce unnecessary administrative tasks and to subject proposed new ones to greater scrutiny before imposing them on doctors and patients.
4. Make sure the push for greater value actually results in greater value.
This one should be a no-brainer. Efforts to bring greater value to health care—defined by Harvard economist Michael E. Porter, PhD, in the New England Journal of Medicine as outcomes relative to cost—should actually result in patients experiencing better outcomes for the dollars spent. Unfortunately, most pay-for-performance programs have not yielded significant improvements in quality or cost savings to the system. While the push to value-based alternative payment/delivery models like accountable care organizations and patient-centered medical homes is showing promise, there is not yet a robust body of evidence to show what elements of each are most effective in achieving the desired improvements.
Further, the measures being used to assess value have been roundly criticized as not measuring the right things while being overly burdensome to clinicians. Congress and the administration should commit to expanding the testing of new delivery models and to fundamentally redesigning performance measures to make them more clinically relevant, more useful, more harmonized, more streamlined, and less burdensome to report.
5. Invest in research and public health.
Congress and the administration should fund programs to prevent and treat opioid use disorders at a level commensurate with the urgent need. Research on the prevention and treatment of disease, on improvement of health outcomes, on the impact of climate change on human health, on prevention of gun violence, and on the social determinants of health should be fully supported. Political ideologies and partisanship should never be allowed to trump good science.
A happy health care New Year would be all about striving to reach agreement on bipartisan and commonsense solutions to make health care better for all Americans, starting with the five issues described above. How about it, President Trump, Senate Majority Leader Mitch McConnell, Senate Minority Leader Chuck Schumer, Speaker of the House Paul Ryan, and House Minority Leader Nancy Pelosi? Can you at least agree to give it a try?