WASHINGTON — With Congress back at work, observers are pessimistic about any chances for major healthcare reform, but some optimism remains around less controversial issues.
“We might see work around stabilizing health insurance markets,” said Fred Isasi, executive director of the consumer group Families USA, at an event Tuesday sponsored by the Council for Affordable Health Coverage, a group of manufacturers, drug companies, and health insurers who stated their aim is to “bring down the cost of healthcare for all Americans. And two places where we may see relatively substantial movement are around prescription drug costs and surprise billing. States have been really active — state capitals have been on fire on [those issues],” and Washington may well follow suit, he said.
Mary Grealy, president of the Healthcare Leadership Council, an umbrella organization for the healthcare industry, noted that “anyone … engaged in getting the Affordable Care Act (ACA) passed realized what a heavy lift that was, so I don’t think we’re going to see massive changes in the healthcare system.” Senate Majority Leader Mitch McConnell (R-Ky.) “has made it clear he is done with ‘repeal and replace’ [for the ACA] … I think repeal is just dead for now,” she added.
Doug Badger, JD, a senior fellow at the Galen Institute, a right-leaning think tank, agreed. “We’re unlikely to see a whole lot out of Washington [but] I don’t view that pessimistically,” he said. Instead, “we’re seeing an enormous amount of activity in the states.”
For instance, state legislatures are not only being proactive by passing their own reinsurance legislation to financially protect the ACA exchanges, they are also working to limit some White House initiatives such as short-term, limited-duration (STLD) health plans. On the other hand, “some states are allowing [STLD plans] to forward, and we’ll see what the effect is. I think the center of gravity in health policy is shifting from the federal government to states, at least for this interim period.”
States also are working to limit their Medicaid programs through the use of tactics such as work requirements for non-disabled, childless adults who have been added to Medicaid programs through the ACA’s Medicaid expansion. “Many conservatives don’t like work requirements … because they think it will make Medicaid expansion more attractive to states that haven’t expanded it,” said Badger. “We’ve also heard the administration talking about perhaps approving partial Medicaid expansion … where you’re on Medicaid up to 100% of the federal poverty level, and then on the ACA above that.”
“The way I look at it, a lot of the great ideas that have come out of healthcare policy from Washington have turned out not to be so great. They’ve been well-intentioned, well-articulated, and well-thought-through, but the results have been less than impressive. Allowing states to try different approaches might actually move us forward in this hyper-politicized environment,” he stated.
Surprise billing, in which patients getting procedures done at in-network facilities are hit with big unexpected charges because one of their providers turns out to be out of network is another area where states have been active. “Across the country, we’re seeing state legislators taking this up and trying to put some guardrails around this,” said Isasi. “It’s the direct experience of American consumers of how nutty [our system] is — you can have an environment where you do everything you can — ‘I want to make sure the hospital is in-network: I want to make sure your physician is in-network’ … and all of a sudden you find out that the anesthesiologist wasn’t.”
ACA-compliant plans are famous for surprise billing, said Badger. “I have a friend who’s paying a $14,000-a-year premium for family coverage; he had back surgery and he had to pay $21,000 out-of-pocket for the surgery,” Badger said.
This also gets into the area of price transparency, he noted, adding that when he recently tried to find out the least expensive place for his own upcoming cataract surgery, “I spent an afternoon calling different providers in my area, and I asked what’s the facility fee, the physician fee, the anesthesia fee, and the fee for the lens, and one of the biggest hospital systems in my area … said to send an email to [a certain] address, but you have to give them the CPT code. [I did it], but a week later, I haven’t heard back. At the very least, there should be a requirement on providers that if a patient wants to know what [a procedure] costs, that they tell them in advance.”
A legislative or regulatory fix might not be the best solution, at least initially, Grealy said. “I think we’re seeing the private sector try to solve that problem as opposed to waiting for a legislative solution and that probably is going to be the better, quicker path. But I think there is bipartisan agreement that it’s something that if it isn’t solved, we probably want to take a look at it.”