Guest Commentary: 'Repeal and replace' is now 'co-opt and confuse'

Congressional Republicans are still actively trying to dismantle the Affordable Care Act, most recently folding repeal of the individual mandate into the tax reform bill.

But what fewer observers may realize is that the Trump administration is also pursuing troubling new directions in healthcare in other, less obvious places.

Recently they've turned their attention to the Center for Medicare and Medicaid Innovation, the agency created by the ACA to test new models for healthcare payment and delivery. This time, instead of "repeal and replace," the strategy appears to be "co-opt and confuse."

The administration wants to take the center's critical work down a concerning new path. Specifically, the CMMI recently requested public comment on a new direction that would "promote patient-centered care and test market-driven reforms that empower beneficiaries as consumers."

At first glance, this sounds hopeful, especially for those of us who are passionate about patient-centered care—by which we mean the movement to ensure that people and families are the focus of healthcare policy, programs and care. The new direction may not be as positive as it sounds, however, notably for the large number of people with complex health and social needs who rely on Medicaid and Medicare.

While empowerment is generally a good thing, this new proposal for the CMMI hints at a strategy that places responsibility on patients and families to act as "super shoppers," scouring the healthcare marketplace for good deals on hip replacements and MRIs, using the power of their pocketbooks to bend the healthcare cost curve. But as most of us already know, finding the right doctor can be challenging enough. Finding medical price information—much less comparing multiple prices—is difficult, if not impossible, and a very different thing from savvy price comparison on shoes or smartphones.

Why? First, there may not be a lot of choice to begin with, given that many parts of the country, especially some rural areas, have few options. For other people, with little disposable income for travel or mobility challenges due to frailty or disability, it may be a huge burden to go far from home to find an alternative source of care.

Then there's the difficulty of obtaining any kind of price information. A recent report card from Altarum that graded states on price transparency and physician quality reporting gave F's to 48 out of 50 states on one or both measures. A 2016 Health Care Cost Institute analysis suggests that less than 10% of consumers' out-of-pocket healthcare expenses are for services that are even "shoppable" at all.

In this context, terms like "patient-centered care," "patient engagement" and "patient empowerment" too often serve as misleading code words for policy prescriptions that actually impose more cost sharing, premium contributions or work requirements on vulnerable families. For people with complex health needs, these approaches are particularly worrisome. There is ample evidence that imposing even small out-of-pocket costs reduces access to care, particularly for people with low incomes or chronic illnesses. In Wisconsin, for example, the addition of a $10 monthly premium made Medicaid beneficiaries more likely to drop out of the program. Numerous studies also link increased premiums to lower health insurance enrollment for poor children.

More person-centered care—the kind we're advocating with the CMMI and across the country—means creating strong and sustainable mechanisms for consumer engagement, ensuring robust oversight, addressing the social determinants of health, valuing primary and preventive care and addressing the needs of people with complex health conditions. This is good for the healthcare system and for all of us. But it only happens when we value the consumer voice and then listen to and act on what people using the health system have to say to improve their care and make our system more equitable.FB01

People with complex health and social needs should have a greater role in improving our healthcare system—not as customers at the healthcare mall but as full partners in the larger discussion about our care and how it is delivered.

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