The Politics of Healthcare Reform

Joseph Alvarnas, MD: What major provisions do you think need to be addressed to ensure wider support across party lines?

Elizabeth Carpenter: I think that might be a bridge too far at this point. But what I would say is that—going back to the 2 sides kind of pulling this issue—it seems like most of the debate right now is focused on the future of the market reforms. And those are things that had really gained a good bit of support and that people recognize. People at home know an insurance company can’t deny you because of a preexisting condition or charge more because you’re a woman.

And those are the things that the Freedom Caucus is looking to return to the states in terms of flexibility. I think they will need to make some kind of deal on how the insurance market is regulated. Once that’s off the table, I would imagine that the debate returns to the Medicaid provisions in the bill that’s being debated—which are highly controversial, that would leave states with significantly less funding. And, of course, that would make states choose whether or not to raise taxes, take some kind of other step to bring in more money, or decrease enrollment or benefits for the people enrolled.

Joseph Alvarnas, MD: Bob, do you see some group of legislative leaders splitting the baby in half in a meaningful way? Is this navigable?

Robert Carlson, MD: I’m frankly not sure. My prediction today is that a year from now, we’ll still be under the Affordable Care Act. It may be modified, but we’ll still be under it, and I think that because many of the changes that would make the ACA acceptable to larger or different constituencies—maybe not larger constituencies, but different constituencies on the Republican side of the aisle—may be unacceptable to their current constituents. I don’t know if they will be willing to pay that political price. That’s my personal view; it’s not my organization’s view. And I think because of that difficulty that they will, in some ways, be disadvantaging some of their own constituents. And a major set of their constituents that tended to vote for them may not find that politically acceptable.

Elizabeth Carpenter: You asked about bipartisan solutions, and I was a little flippant. At my core, I’m inherently bipartisan and a policy nerd, so I’m led to believe it’s possible. So, I do want to be clear about this: there are a set of reforms that could be capable of achieving bipartisan support, but they would focus on stabilizing the Affordable Care Act. Additional support for reinsurance programs and other kinds of state-based risk programs is something that could gain traction and make the market more attractive for insurance companies. Some of the market reforms letting premiums vary more based on age is something that has been reviewed as potentially bringing younger, healthier people into the market.

Certainly, focusing on fixing—and this is a problem, certainly, for our health plan colleagues here—the risk-adjustment mechanism to make sure that it is accurate and compensating plans appropriately—is a thing that could really shore up the existing Affordable Care Act. And if members on both sides of the aisle decided that was their goal, there is certainly a path forward there—it’s just a question of whether Congress gets to that place or not.

Joseph Alvarnas, MD: John, predictions?

John Fox, MD: I wish I had good predictive ability. If I did, I might not be in this job. What I hope is—and I think this might be a forlorn hope—that calmer heads will prevail and will make the modifications that preserve the access that people now enjoy. Rand Paul’s father—a representative, previously an OB GYN physician from Texas—when asked about healthcare coverage, said, “Well, if people don’t have insurance, they can do soup suppers and spaghetti dinners.” Healthcare is just too expensive today, and it can ruin families. Diseases already ruin families. We don’t need finance to do the same, and I think you’ve outlined several key things that can be done to stabilize it. I hope that it’s the calmer set of heads that prevails on all of this. I think representatives and senators recognize, from the feedback they’ve gotten in their districts and in the meetings in their districts, that there is a lot of emotional energy built around this. And I’m hoping that that will translate into calmer heads.

Elizabeth Carpenter: And there may be a catalyst for this. We’ve seen in Tennessee that there are 16 counties that won’t have an insurance company on the exchange next year unless someone else comes in. Republican senators Bob Corker and Lamar Alexander have introduced legislation to allow individuals to take the financial tax credit assistance provided under the ACA and use it to purchase a plan off of the exchange. I think we will see additional counties and areas in the country faced with that challenge, and it may be the catalytic moment to ask, “What are we doing here?” We’re putting on a Band-Aid without addressing the problem, so there will be several inflection points in this debate—and, certainly, carrier participation for the 2018 plan year will be one of them.