Health Care Under Trump

Making American Health Care Great Again, by Repealing and Replacing the ACA

Article · October 18, 2017

During the past election season, much of the discussion we heard about health care focused on the Patient Protection and Affordable Care Act, better known as the ACA — and most often what is wrong with it. Now that we know that our executive leadership and both the House and Senate are Republican, with a pledge to repeal and replace the ACA, what should really happen?

Without question, some things have not worked out so well as a result of this landmark legislation, but there is a lot that is right with the law. President-elect Trump’s new health care team should carefully weigh the good and the bad.

The ACA broadly sought to create a high-value system by improving access to health care, and to change the U.S. health care delivery system so that costs are reduced and outcomes of care are better. A new Congress can address what was wrong and keep what makes sense. This is a great opportunity we would not have had if not for a dramatically disruptive election.

Access to health care has improved for many Americans as a result of the ACA’s dramatic reduction in the number of people without health insurance. At MD Anderson Cancer Center, some patients tell us that getting insurance through the exchanges allowed them to get treatment for their cancer. Patients with preexisting conditions cannot be denied insurance. Children can stay on their parents’ insurance longer. These advances have to mean something to even the most severe critic of the ACA.

Yet there remain uninsured people, and the costs of health insurance are increasing even on the exchanges. Rising insurance prices and the rapid emergence of narrow networks keep patients from getting care with better providers. These issues must be addressed. All Americans need access to providers who offer the best outcomes. Market forces should not drive consumers only to low-cost providers because — as much as we do not want to admit it — you get what you pay for, even in health care.

While details of Republican plans to replace the access portions of the ACA have yet to emerge, two principles need to be emphasized:

  • There should be significant incentives to Americans to be insured.
  • The narrow network concept, which benefits only the insurance industry, should be eliminated.

Accelerating Value in Health Care Delivery

Beyond the access provisions of the ACA, perhaps the greater opportunities lie in the framework created to improve care delivery and control cost. These are critically important concepts in redesigning America’s delivery system. One of the real opportunities in a repeal-and-replace scheme is to place an even greater emphasis on value creation in our system, and to try even harder to hardwire approaches that improve outcomes that matter to patients and control costs.

The ACA has accelerated the movement to value-based health care. The term “value” was used several hundred times in the bill. The push to reimburse hospitals based on quality measures gave credibility to the value concept, and has led to multiple other value initiatives coming from CMS, culminating in the 2015 goal to move the majority of CMS payments to value-based payments over the subsequent three years. The emphasis on value also resulted in the replacement for the SGR bill, MACRA, to further accelerate alternative reimbursement models and the use of outcome measurement, including patient-reported outcomes, for quality assessment.

Preserving ACA Successes: The Innovation Center and PCORI

Of all the programs in the ACA, a major success is the Center for Medicare & Medicaid Innovation. CMMI was created to test new and innovative reimbursement and delivery models. It has supported the testing of accountable care organizations, which may not be living up to their expectations to control cost and improve quality — which is exactly why these programs are being tested. CMMI has rolled out multiple evaluations of bundled reimbursement to see what works to control cost and improve quality. The law also stipulated that if CMMI shows that a particular program works well, the Health & Human Services Secretary can implement it straightaway, eliminating delay. CMMI has also turned America’s largest provider of health insurance, CMS, into its most progressive. It is also piloting programs to transform primary care.

Of course CMMI could do more. At the current rate of testing these reimbursement models, it could take decades to get us out of the fee-for-service system into new reimbursement models that reward good results. A replacement bill should keep CMMI and accelerate its testing and implementation of alternative payment models (like bundling) to many more conditions. Once CMMI demonstrates the success of these programs and physicians see that they can be rewarded for achieving good outcomes that matter to patients, then other insurers will get out of the fee-for-service business and be more willing to implement bundled reimbursement.

Another tremendous success of the ACA has been the creation of the Patient-Centered Outcomes Research Institute (PCORI). For the first time, there is peer-reviewed funding for testing of health care issues that matter to patients. Looking at patient-centered outcomes has transformed comparative effectiveness research (CER) into a robust field that answers questions about care delivery overlooked in other forms of clinical research. Traditional funding agencies did not address how to help patients make decisions about the care they need, and how to include patients in the research team that designs and executes these studies.

PCORI can also do more. It should fund more CER studies. The National Academy of Medicine has identified over 100 high-priority areas for CER, of which PCORI has touched only a fraction. Additionally, the ridiculous, politically motivated stipulation that PCORI-funded research cannot consider costs of care needs to be erased, so that health care decision-making becomes transparent. How can one assess outcomes without addressing cost?

Numerous other provisions of the ACA have important impact, such as the requirement for insurance coverage of patients on clinical trials and the introduction of a broad-based program to support disease prevention programs. Their ultimate impact has yet to be fully realized.

Clinical Leadership Is Critical

A final consideration: If the federal government is to truly lead the needed transformation of health care, there must be more coordination between Congress and the Department of Health & Human Services from the outset of the new Administration. President-elect Trump needs a clinician in his cabinet to lead that effort as HHS Secretary. Credibility will come from someone who has actually cared for patients and understands value in health care. Congressional leaders need to work collaboratively with the new Secretary to pass a replacement law that will work for patients and will be embraced by clinicians as a new path forward in health care. Using the value framework of the original ACA, the new Administration can make American health care great again.


This post originally appeared in NEJM Catalyst on November 18, 2016.

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