Health Reform 2011: Beyond the Affordable Care Act
As the fight over health reform increasingly shifts to individual states, executive agencies, and the courts, members of Congress can continue to shape the debate, address legislative shortcomings, and shift their focus to spiraling healthcare costs. Though the political stakes may seem high, pro-reform politicians should remember that many claims made about the Patient Protection and Affordable Care Act of 2010 (“ACA”) were also made about now largely unquestioned Medicare and Social Security programs and history may provide the ultimate validation for legislators intent on increasing access to healthcare. Though Republicans have been vociferous in efforts to repeal, de-fund, and de-stabilize the ACA, Democrats have presented a united front that has largely protected main components of the law. However, Democrats must remain vigilant to prevent the ACA’s slow death by amendment and should continue to defend this historic, hard-fought legislative victory.
As an advisor to Senator Tom Harkin, I would focus on three strategies to protect and advance health reform. First, Sen. Harkin and Democratic leaders should take back a public relations firestorm dominated by conservative voices. Second, Sen. Harkin should advocate for payment reform to address rising healthcare costs. Third, Sen. Harkin should advocate for limited legal and policy concessions to Republicans. Though the majority of these proposals are likely to be met with opposition, these steps are needed to advance health reform and continue the United States’ transition to one of the finest health systems in the world.
Reclaiming Public Opinion in Support of Health Reform
Democratic leaders have been charged with failing to develop a cogent public relations message surrounding healthcare reform, thereby creating a communication vacuum that was quickly filled by opponents crying death panels and rationing. The messaging imbalance is most strongly evidenced by the fact that nearly half of Americans are confused about the status of the ACA and twenty-two percent believe the law was repealed. In response, Sen. Harkin should lead the way in defending the ACA but also representing the majority of Americans that oppose defunding the law. Though one might argue that Democrats should avoid the thorny issue of healthcare reform, simply ignoring efforts to undermine the bill could be costly as voter groups such as the elderly begin to show diminishing support. By avoiding the discussion or erecting a half-hearted response, Democrats risk support they cannot afford to lose.
Though Democrats have successfully touted popular provisions of the ACA, this strategy has brought limited success. Instead, Democrats could appeal to conservatives by emphasizing that exchanges are consistent with Republican values of transparency and consumer choice or highlighting the law’s flexibility and respect for state innovation. Democrats should also reframe the justification for the individual mandate while developing alternatives should the provision be found unconstitutional. For example, the individual mandate could be recast as an issue of individual personal responsibility whereby taxpayers no longer shoulder their neighbors’ burden. These framing adjustments could help endear the support of critical independent voters.
Heavy Lifting: Bending the Cost Curve
Second and perhaps most importantly, Sen. Harkin should address payment reform and the burden of healthcare costs on state governments. Sen. Harkin should immediately engage key stakeholders, such as the American Medical Association, to transition from fee-for-service to value-based reimbursement that financially incentivizes positive health outcomes. Though value-based reimbursement could result in “patient shopping” by physicians for the healthiest patients, the system could include tiers with greater reimbursement for positive health outcomes from less healthy patients. A value-based system need not result in poor doctor pay and the quality of the doctor-patient relationship would improve, as evidenced by experiences at facilities such as the Mayo Clinic and Group Health. Sen. Harkin should note that even if accountable care organizations (“ACO”) are successful in curbing health costs, questions remain about ACO legality and ACO creation should not foreclose meaningful payment reform.
Though Congress’ role here may be limited, states have increasingly demanded support or alternatives to ACA implementation. Sen. Harkin should support Secretary Sebelius’ proposals to manage state Medicaid spending and emphasize managed care for “dual eligible” patients through the ACA-created Federal Coordinated Health Care Office. Sen. Harkin could also investigate whether “dual eligible” status is most appropriate for the poor elderly, support the efforts of Medicaid “savings squads,” and heed advice by the Federal Coordinating Council for Comparative Effectiveness Research to best promote the public’s health in the most cost-effective manner possible.
Necessary Evil: Concessions to the GOP
Democrats should make limited legal and policy concessions such as addressing medical malpractice reform and flexible spending accounts. Though medical malpractice reform has been politically untenable for Democrats, Sen. Harkin should address criticism for the failure of the ACA to introduce medical malpractice reform. While Republicans support statutory damage caps, recent empirical studies on medical malpractice payouts in Texas suggest that caps have limited effectiveness and are unlikely to affect physician premiums. To promote comparable state data systems, Sen. Harkin could require closed claim databases in states that implement exchanges, thereby improving access to data needed for meaningful policy changes. Sen. Harkin should also alter the “use it or lose it” rule for flexible spending accounts (“FSA”) to complement the corresponding provision in the ACA that limit annual FSA contributions and make the FSA less likely to be abused. Sen. Harkin could propose allowing individuals to cash out and pay taxes on any unused portion of the FSA at the end of the year.
I would vigorously recommend these and similar measures to promote healthcare reform. However, I would do so with the politically realistic understanding that there will be many compromises on healthcare before the presidential election in 2012. Though less than ideal, these compromises are acceptable if they garner support for President Obama’s reelection. Without that reelection, the hopes and dreams of uninsured Americans eager to join the ranks of the insured may be dashed. Thus, Sen. Harkin should lead members of Congress in being steadfast in defending and proactive in improving recent legislative successes.