What no one is talking about in the "repeal and replace" debate

An Iowan with in-depth knowledge of the health care sector looks at lesser-known benefits that could be lost if Congress replaces the Affordable Care Act. -promoted by desmoinesdem

The debate on Republican efforts to repeal and replace the 2010 health care reform law has focused on the provision of health care and the repeal of some taxes. In particular, attention has been directed at the effort to reduce Medicaid coverage.

What isn’t being discussed: the Affordable Care Act (ACA) included many provisions aimed at addressing serious issues in the health care system, such as quality, safety, and workforce shortages. None of those can be found in the House-approved American Health Care Act (AHCA) or the Better Care Reconciliation Act (BCRA), proposed by Senate Republican leaders.

So, in addition to reducing (or eliminating) coverage for poor people and individuals with illnesses, the Republican bill would be a step backward in terms of efforts to improve the health care system, which accounts for 17 percent of our gross domestic product.

To review, the main provisions of the ACA were the expansion of the Medicaid program, the “individual mandate” (the requirement that everyone have health insurance), the requirement that employers of more than 50 people offer employee health insurance, and the subsidy that helped low-income people purchase insurance through the health care exchange.

The “individual mandate” was critical because it meant that the pool of insured would include everyone, so the cost of premiums could be spread across the population that included young and healthy people, as well as people with pre-existing conditions, people at risk of illness, and people in poor health. The ACA required insurance plans to cover people with pre-existing conditions and allowed children to stay on their parents’ insurance plans until age 26.

In addition, insurance plans could not be offered unless they covered ten essential services: 1) ambulatory services; 2) prescription drugs; 3) emergency care; 4) mental health services; 5) hospitalization; 6) rehabilitative and habilitative services; 7) preventive and wellness services; 8) laboratory services; 9) pediatric care; and 10) maternity and newborn care.

The AHCA, which House Republicans passed in May, does not assure coverage for any of these services and does not protect people with pre-existing conditions. Perhaps of most concern to people who consider the health care system flawed, the AHCA does not contain any measures that will evaluate or improve the current system.

In contrast, the ACA, in Title III, “Improving the Quality and Efficiency of Health Care,” required the establishment of a national strategy to improve health care delivery, patient outcomes and population health. It established a Center for Medicare and Medicaid Innovation to research, develop, test, and expand innovative patient care options. It established study groups and demonstration projects aimed at improving access to rural health care, and supporting small rural hospitals.

Title IV, “Prevention of Chronic Disease and Improving Public Health” was aimed at re-orienting the nation’s health care system toward health promotion and disease prevention. As any health economist will tell you, the key to achieving a reduction in health care cost lies in keeping people out of the hospital: preventing chronic illness through lifestyle changes and managing chronic illness on an outpatient basis. Title IV focused on increasing access to preventive services, establishing a national prevention and health promotion strategy, and developing a national public-private partnership to conduct prevention and health promotion outreach and education campaigns.

The same section of the current law also authorized several important new programs, for the operation of school-based wellness clinics, for an oral health education campaign, and Medicare coverage for 100 percent of the cost of preventive services. In addition, it provided money for grants to communities for wellness initiatives, authorized the Centers for Disease Control to undertake pilot programs for 55-64-year-olds to evaluate chronic disease risk factors, and provided funding to study best prevention practices and evaluate the most effective employer wellness programs.

Title V, “The Health Care Workforce” established a National Health Care Workforce Commission to review current and projected workforce needs and to provide information to Congress and the administration to align federal policies with national needs. In addition, it set up loan programs in areas of critical shortages, supported workforce training programs in areas such as rural physicians, direct care workers in long term care facilities, geriatric practitioners, family caregivers, family medicine, pediatrics, dentistry, mental and behavioral health practitioners.

Title VI, “Transparency and Program Integrity” established rules to reduce fraud in public programs and protect patients by providing them with additional information. For example, nursing homes must make information about their ownership public, and information about staffing, certification, complaints and violations must be available on a Nursing Home Compare website.

In addition, nursing care facilities are required to train all staff members in dementia management and abuse training. Title VI set up a detailed and comprehensive set of program integrity provisions for the Medicare and Medicaid programs. It also included the “Elder Justice Act” which is aimed at preventing elder abuse, neglect and exploitation.

Title VII, “Improving Access to Innovative Medical Therapies” established a procedure under which the FDA will license a “reference product” and addresses the approval of biosimilar or interchangeable products. It also extends a program through which drug companies provide medications at a discount to some hospitals such as rural hospitals, children’s hospitals, and cancer centers.

Title VIII, “Community Living Assistance Services and Support” established a revenue-neutral program for people with functional limitations

Title IX, “Revenue Provisions” contained all of the tax provisions that fund the expansion of services. All would be repealed under the AHCA, which provides a tax break to families with incomes of over $250,000. Under the ACA, those families paid an additional 0.9 percent on income over $250,000, which the Republican bill would eliminate. The AHCA would also remove the assessment of the insurance and pharmaceutical industries and eliminate the requirement that health insurance companies spend 85 percent of the premiums received on providing services to the people they insure.

Title X, “Strengthening Quality and Affordable Care” contains a variety of provisions aimed at improving the health care system. Examples are: creation of incentives for states to shift Medicaid beneficiaries out of nursing homes into home and community-based services; establishing a Pregnancy Assistance Fund for the purpose of awarding matching grants to states to assist pregnant and parenting teens and women; improving health care coverage for individuals exposed to environmental health hazards; grants to medical schools to recruit students from rural areas who want to practice in their home towns; grants to small businesses seeking to develop workplace wellness programs.

There are a lot of additional sections I haven’t mentioned. Republicans have often criticized the length of the ACA. Those roughly 900 pages included many important policies that are completely lost in the current debate. The ACA was a serious effort to address significant issues. Not just the fact that, at the time of its passage, 45 million Americans were uninsured, but also escalating health care costs and significant disparities in quality, depending on where care is delivered. (Low-income people and racial minorities get poorer care and have worse outcomes throughout the lifespan, and health care dollars are distributed unequally.) The ACA tackled all of that.

The American Health Care Act, in contrast, has a simpler focus: removing health care coverage from those who can’t pay for it themselves, and removing protection from those who have pre-existing conditions. Don’t believe it when they say that those people are protected. They’re not. I used to be a pediatric critical care nurse, and I cared for babies born with heart defects. They had a “pre-existing condition” for life, and, until the ACA, couldn’t get insurance unless they got a job with really good employer-based coverage. Sometimes not even then.

The AHCA will not provide coverage if you are poor, have spent all your assets getting care, have a chronic illness, are in an accident, or want to get regular check-ups or take medication. The bill is a tax break for the wealthy and the insurance industry, pretending to be a health care bill. It is shameful.

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  • The future?

    I read somewhere that the U.S. is bound to end up, sooner or later, with a two-part health care system — single payer for most of us, boutique care for the rich.

    • We have two-part health care already

      The best health care (defining ‘best’ in terms of health outcomes) in the US goes to 1) people with private insurance, 2) seniors on Medicare, or 3) those who pay cash.

      The worst health care in the US goes to 1) people on Medicaid, or 2) who receive their care from the VA system. You will notice these are both run by the government.

      People with no insurance at all, and no money at all, are somewhere between these two extremes.

      Switzerland is not perfect, but it is a model we should at least strive for in terms of what they get for their money. Their health care results are just as good as ours and they pay quite a bit less for it.

      Singapore has another excellent health care system, possibly better than Switzerland’s.

      • Government-run healthcare is just as good and costs much less.

        Looking at international comparisons, the UK’s national healthcare has outcomes that are as good or better than the U.S. The costs are much less than ours and less than most other countries with universal care. Switzerland’s system may cost less than the U.S. system, but it costs nearly twice as much as the U.K. system.

        Medicaid and VA care have been underfunded. The VA system may be the most cost-effective system in the U.S.