Well, it is over. We are going to swear in a new president who has vowed to repeal the Affordable Care Act and replace it with, in his words, “something great”.
Even the most ardent proponents of ACA readily admit there is room for improvement, but 20 million previously uninsured Americans are insured today because of Obamacare. (And, they would like to have more details about what “something great” actually means.)
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Lost in the political wrangling is that the ACA included much more than the individual health insurance mandate. It was a huge, comprehensive piece of legislation that also mandated testing of alternative payment models. Many of these alternative payment models have already been designed and executed, and many more are in the process.
The ACA was designed, in part, to develop innovative payment models to replace our fee-for-service system, which has been sick for many years, and the only cure is a transplant. Fee-for-service must be replaced with value-based care models. Fee-for-service has failed because it lays a foundation of perverse financial incentives: it rewards healthcare providers for providing more care to more people instead of the right care to the right people.
As one example among many, section 3021 of the ACA established the Center for Medicare and Medicaid Innovation (CMMI) and appropriated $10 billion for programs initiated between fiscal year 2011 and FY 2019. The CMMI is “tasked with testing innovative healthcare payment and service delivery models with the potential to improve the quality of care and reduce Medicare, Medicaid, and CHIP expenditures.”
The CMMI hasn’t been sitting still. The center has been busy developing a number of innovative programs that will affect healthcare for years to come, including bundled payment models, new ACO models, and the Comprehensive Care for Joint Replacement (CJR) program. Many of these programs have already affected our professions, and many more will have a lasting effect on the future of healthcare.
These programs have great promise for achieving the “triple aim” goals of providing more effective care, improving patient satisfaction, and decreasing overall costs by getting the right care to the right people. As an example, the CJR program aligns the incentives of hospitals, orthopedic surgeons and physical therapists to improve care coordination, quality, and functional outcomes for patients undergoing total hip and knee joint replacements. There is ample room for improvement as evidenced by a huge variance in quality scores and costs for these procedures in different geographic regions.
As a physical therapist, I am very excited by the opportunity afforded by the CJR to innovate and provide great care for this population of patients. PTs, working more closely with orthopedic surgeons and hospitals than ever before, can play a vital part in making sure that patients receive the care they deserve without the burdensome constraints and perverse incentives of fee-for-service. For example, there are exciting innovations in telehealth that would allow a PT to effectively monitor a patient’s progress without as many face-to-face visits. Discovering problems with a patient’s recovery early allows us to get the patient the care they need immediately, and decreases costs in the process.
It is hard to see how a flat repeal of the entire Affordable Care Act is practical or politically tenable. It is simply naive to believe that the ACA can be simply “unwound” at this point without catastrophic and largely unanticipated consequences for millions of people. In my opinion, an outright repeal of the entire ACA is only slightly more likely than an outright repeal of Medicare. At the time of this post, it seems obvious that Mr. Trump is backing down from his most strident rhetoric on replacing the ACA with “something great”. The good news is that he is capable of changing his mind as evidenced by his “evolving” views on healthcare over the years.
The ACA genie is out of the bottle. It is not perfect, but it does represent an improvement. Abandoning the individual health insurance mandate would be catastrophic for millions. Rolling back innovative value-based payment models will leave us with a dysfunctional healthcare system for many more years to come.
It is my personal hope and belief that cooler heads will prevail and the ACA will ultimately be improved, but not disbanded. Mr. Trump, my twitter handle is included in this article. You can direct message me anytime.
Photo: Dmitrii_Guzhanin, Getty Images
