The congressional effort to repeal and replace the Patient Protection and Affordable Care Act is like an iceberg: The part that isn't visible has the greatest potential to cause serious damage.
While politicians and lobbyists duke it out in Washington, providers worry about what to do next
That effort began last week when the U.S. House of Representatives voted 245-189 to repeal the 2010 healthcare reform law with support from all 242 House Republicans and three Democrats: Reps. Dan Boren of Oklahoma, Mike McIntyre of North Carolina and Mike Ross of Arkansas. The only non-voting member was Rep. Gabrielle Giffords (D-Ariz.), who remains in serious condition after being shot in Tucson, Ariz., on Jan. 8.
The morning after the Jan. 19 repeal vote, House members approved a resolution that directs four House committees to consider 12 guidelines as they draft legislation to replace the Affordable Care Act.
While some of the nation's biggest healthcare lobbying groups—including the American Hospital Association—did not take official positions on last week's actions, providers said their greatest concern lies in what House leaders will do next to undermine the law, which remains to be seen.
“We view the current effort of repeal as background noise,” said Dr. William Walker, director and public health officer at Contra Costa Health Services in Contra Costa County, Calif. “We're more in fear of what will happen month by month and year by year.”
Walker said he worries the repeal effort is the first step in what could be a continued attempt to unravel the reform law, either through pieces of legislation that could overturn parts of it, or through obstacles in funding it adequately. Contra Costa serves a county of about 1 million through its public system that includes 146-bed Contra Costa Regional Medical Center, nine clinics that serve about 480,000 outpatient visits a year, and a health plan that covers 90,000 managed lives.
“This is the first hope I have for not only expanding appropriate healthcare coverage, but providing some rationale for reforming the current non-health system we have in the U.S.,” Walker said.
The law stirs hope for Walker in three key areas: incentives for hospitals and physicians to produce good outcomes for patients rather than income for themselves; an emphasis on evidence-based healthcare; and a push for quality and safety in how systems operate. And he said he has seen the law already produce results—such as in patients who have received relief in the doughnut hole of Medicare prescription drug coverage and employees who can now keep their young adult children on their insurance plans—and that it should be given time to develop before it's dismantled.
Representing the nation's insurers, America's Health Insurance Plans said last week in an e-mailed statement that the group continues to believe changes are needed to the law “in order to minimize coverage disruptions and cost increases for families and employers.”
Meanwhile, American Medical Association President Cecil Wilson said in a statement that the AMA does not support repealing the Affordable Care Act because it includes market reforms and initiatives to promote wellness, which align with the association's policy objectives. But, he added, the AMA is pushing for changes that would more deeply address medical liability, alter the framework of the Independent Payment Advisory Board, and eliminate an IRS 1099 reporting requirement, which businesses complain is burdensome.
Patrick Smith, vice president of government affairs at the Medical Group Management Association—which did not take a formal position on the repeal bill—said the legislation was a political statement, and that the real question is what the House committees will do next with regard to the replacement resolution. Much to the frustration of Democrats, the resolution does not include a deadline for these committees to submit their work.
On the House floor last week, Rep. Jim McGovern (D-Mass.) called the replacement resolution “a series of talking points,” that lacks any real language with real benefit.
The resolution, introduced by House Rules Committee Chairman David Dreier (R-Calif.), calls upon the committees to consider a dozen guidelines as they draft legislation, such as providing states greater flexibility to administer Medicaid programs; lowering healthcare premiums through increased competition and choice; providing people with pre-existing conditions access to affordable healthcare coverage; and reforming the medical liability system to reduce wasteful healthcare spending. House members already started work on that last issue, as the House Judiciary Committee held a hearing on medical liability reform late last week.
“I wouldn't be surprised if it's marked up in the next few weeks,” Smith said of potential legislation. “The major sticking point, of course, is the cap on non-economic damages,” he added. “I would expect the bill to pass the House with some type of bipartisan fashion.”
The replacement resolution also included one amendment to make a permanent fix to the physician payment system, which received support from 428 members, with one member—Rep. John Conyers (D-Mich.)—opposing it. Five members did not vote on the measure.
All of this adds to the significant uncertainty providers are already experiencing, Smith noted, with a 30% cut in Medicare physician pay set for the end of the year and the legality of the reform law's individual mandate apparently headed to the U.S. Supreme Court.
Last week, six more states—Iowa, Kansas, Maine, Ohio, Wisconsin and Wyoming—joined 20 other states and the National Federation of Independent Business in a Florida-based lawsuit to halt the reform law. Other suits challenging the law are working their way through the federal appeals courts.
Outside of Washington, MGMA members are “focused on everything else but this,” Smith said of repeal and replace efforts. Instead, members are working to qualify for meaningful use; wondering if physicians' exemption to the so-called red flags rule (which compels creditors to prevent identity theft) is truly final; and waiting for the release of a host of federal regulations, including the much-anticipated rule on accountable care organizations.
That's also the case for providers at NuHealth System in East Meadow, N.Y., according to Art Gianelli, the system's president and CEO.
NuHealth has four community health centers, a freestanding diagnostic center, a school-based clinic, and one hospital—481-bed Nassau University Medical Center—which has a payer mix that includes 50% Medicaid and about 20% Medicare.
Gianelli said the system is busy at work on meaningful use and preparing itself to be eligible if and when ACOs, bundled payments or other demonstration projects are launched.
“The actions this week were symbolic in fulfilling a promise in the campaign,” Gianelli said Jan. 20. “The reality is that the Senate will not take the repeal bill up, and the repeal bill will die there,” he added. “The real action,” Gianelli said, will come from the House's efforts over the next two years to defund the law, and any delays or confusion in implementation will have a “long-term deleterious impact” on the nation's healthcare system.
Gianelli also said the actions in Washington last week—in which the House majority sought a quick repeal and healthcare lobbying groups generally opposed that move—mirrors the views of the general public, which is “generally split” in its views on health reform.
“I'd argue that we have the best doctors in the world; we have the best hospitals; we provide the best care. You can have wonderful players on a bad team,” Gianelli said, adding that when this happens, a team can't leverage its talent to the fullest level.
“We're not organized correctly,” Gianelli said of the current system. “That's the problem, and I think that's what the Affordable Care Act addresses.”
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