Last Tuesday’s election upended a lot of longstanding truths in American politics — or more accurately, revealed what many thought were truths to be merely assumptions. In their place are a lot of questions and very few answers, ranging from larger issues such as how our President-elect will govern, and how he will (or will not) work with Congress, to what will happen to aspects of the Affordable Care Act — both the unpopular features (exchanges and the individual mandate) and popular (guaranteed issue and coverage of children up to age 26).
While the election may have created uncertainty for U.S. health care, the cost and quality pressures that have long faced providers, payers, and patients remain a serious issue for the new Administration. Under the ACA, regulators had hoped to let a thousand reform flowers bloom, yet many of those solutions — such as ACOs and bundled payments — have shown no more than modest success.
At the moment, it seems likely that health care financing will get more attention than health care delivery under the new Administration. Medicaid expansion may be rolled back in some states, and block grants are likely to constrain state Medicaid plans — though a fixed Medicaid budget may drive a more rapid shift toward value-based care in many states. The aspects of the ACA that have attracted the most public attention — the individual and employer mandate, and insurance exchanges and subsidies — are most likely to see significant changes. The biggest question comes as the President-elect has recently indicated that he wants to maintain guaranteed issue, but it is unclear how the integrity of the insurance markets could be maintained without some sort of mandate.
Nevertheless, while there is a significant chance that the specific mechanics of reform may change, the interest in and demand for value-based care will persist on both sides of the aisle. This can be seen in the 392-37 and 92-8 House and Senate votes that passed MACRA, which established a permanent “doc fix” to Medicare reimbursement rates in exchange for a choice between a complex series of quality and efficiency measures, or participation in risk-bearing value-based payment models.
Looking ahead, it is possible that there may be a push for a less-regulated approach toward new models, with state Medicaid plans, private payers, and employers taking more of a lead as a result of a more hands-off CMS and a move toward federal Medicaid block grants. The result could be net positive for innovators in health care, as an even more diverse range of delivery reform approaches is tried — though incumbent providers and payers may be challenged to adapt to yet another changing landscape. Many states and their providers, however, could be financially adversely affected by block grants.
One thing is clear: all of us in American health care need to take an active role in setting our own future course. Problems like the burdens of chronic disease and mental illness persist, and we need to address these issues. We need to acknowledge that health care cost growth over the past three decades has contributed to middle-class wage stagnation, so we have to take responsibility for the cost problem in health care, even if that means challenging business and behavior models along the way. If we are unable to establish a collective vision for change — and a meaningful roadmap for achieving it — then change will be imposed upon all of us with unintended consequences.
This blog post originally appeared in NEJM Catalyst on November 15, 2016.