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Health policy shaper: Congress can get things done

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To a health policy watcher outside of Washington, it may look as if the Republicans in Congress have no sincere interest in making Patient Protection and Affordable Care Act (PPACA) rules and programs work better.

It may look as if the Democrats have little interest in admitting that any significant PPACA problems exist, let alone in talking candidly about ideas for fixing the problems.

Joel White, president of Horizon Government Affairs and president of the Council for Affordable Health Coverage (CAHC), said he sees things differently.  

In spite of all of the talk of Republicans moving farther to the right, and Democrats moving farther to the left, White said there are still plenty of pragmatists on both sides who want to find ways to make the health care system work better.

“We work with them every day,” White said.

CAHC helps health insurers, the National Association of Health Underwriters (NAHU), the U.S. Chamber of Commerce, pharmaceutical groups, and provider groups, such as the American Academy of Ophthalmology, promote their proposals for using market-based mechanisms to improve the quality of the U.S. health care system and hold down the cost of care.

CAHC has lobbied for ideas such as limiting hospital mergers, improving implementation of electronic health record (EHR) standards, and having private websites take over at least some of the functions of the PPACA private exchange system. 

White, who worked on health issues on the staff of the House Ways and Means Committee from 2001 to 2007, said at least 12 PPACA changes have become law since President Obama signed the bills that created it and its sister, the Health Care and Education Reconciliation Act of 2010 (HCERA).

See also: Obama Signs 1099 Fix Bill

This year, for example, a new measure will expand the amount of public health program data the U.S. Department of Health and Human Services (HHS) shares with private entities. Another, better-known measure has given each state the ability to decide whether the maximum size of a small group in its jurisdiction should be 50 employees or 100 employees.

“We wouldn’t have gotten these two laws signed” if there weren’t still pragmatists in Congress, White said.

White said some policymakers who look in public as if they have dug in their heels sound more flexible when they are talking behind closed doors.

For Democrats, he said, the wave of failures of Consumer Operated and Oriented Plan (CO-OP) carriers is one reason for soul searching. A second reason is lower-than-expected public exchange plan enrollment numbers.

A third reason is the difficulties accountable care organizations (ACOs) have had with producing big, obvious gains in health care system efficiency.

In the 1990s, some big group health provider practices agreed to take a flat “capitation” fee per provider served, in the hope that they would have the flexibility to manage patients’ care in a flexible way, hold down the overall cost of care, and improve the quality of the care patients were getting. Many of those capitated practices failed, amidst reports that they ran into serious problems with tracking and forecasting patients’ use of care.

In recent years, Democratic policymakers have hoped that accountable care organizations (ACO) — provider-run health plans that assume some health care service demand risk, rather than all of the risk — could use modern computer systems to succeed where the old capitated group practices failed. The idea was that the rise of the ACO might increase the efficiency of the health care system enough to hold down costs without pushing policymakers, private plan managers or health care providers to limit patients’ access to care in annoying, or potentially harmful, ways. 

Some ACOs are doing well, but, in general, they have not turned out to be the health care system saviors advocates had hoped they might be, White said.

For Republicans in Congress, the need to help constituents who have lost CO-OP coverage, or who are having problems with public exchange plans, may be increasing interest in finding ways to help the constituents, not just blame the other side, White said.

See also: N.Y. CO-OP exiles face confusion, dash for new coverage

Last year, White said, some policymakers were talking happily about how well the country was controlling the cost of health care and health insurance. “No one’s talking about that anymore,” he said, citing reports of big 2016 individual and small-group rate hikes in many communities. “This is a hard, hard market.”

Given how much prices are increasing in 2016, and how much prices seem likely to increase in 2017, controlling costs will probably be the top issue for members of both parties in 2017, White said.

Republicans have clearly made replacing PPACA one of their top goals. Once the Obama administration leaves office, Democrats in Washington may also be more open to conversations about improving PPACA, White said.

One driver may be policy shapers’ own personal encounters with the PPACA public exchange system.

PPACA requires members of Congress and some of members’ aides to get their own health coverage through the public exchange system, rather than through the Federal Employees Health Benefit (FEHB) plan. The U.S. Office of Personnel Management (OPM) has told members of Congress to sign up for health coverage through the small-group division of the DC Health Link exchange.

White said his impression is that the experiences of the lawmakers who are using the exchange system are “generally very negative.”

“They really don’t like it,” White said.

See also: What could members of Congress pay for coverage?