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Blue House, Red Senate: What Now For American Healthcare?

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Unlike the 2016 presidential election, which surprised pollsters, the 2018 midterms panned out as predicted: Republicans kept the Senate majority and Democrats wrested control of the House.

With these results, the partisan divide in Congress is widening before our eyes. This congressional split bodes poorly for the 71% of voters who labeled healthcare as “very important” in determining their vote.

After enduring months of healthcare policy ads, patients are eager to know which (if any) promises the 116th Congress will keep. And because many promises were made, I asked would-be voters to get specific about which healthcare issues matter most to them.

Let’s focus on the top six responses from this survey to find out whether leaders of Congress are likely to address any of these issues in the next two years. Of course, divining the future of healthcare is an exercise fraught with hazard, but educated guesses can be made. Here are my thoughts and predictions, each informed by recent conversations with Washington insiders.

1. Rx Prices

The first 10 bills introduced by the leadership of the new majority party (H.R.1-10) are referred to as “message” bills, designed to pay off campaign promises and send a clear message about congressional priorities.

Addressing the high price of prescription drugs is the House Democratic majority’s biggest opportunity to enact meaningful change on behalf of the American people. The question is whether Nancy Pelosi or Steny Hoyer (the two leading candidates for House Speaker) will attempt to pass a bill by reaching across the aisle. Already, their Republican counterparts have expressed interest in doing the same.

In October, President Donald Trump and HHS Secretary Alex Azar described a plan that would establish an “international pricing index for Medicare Part B (what the government pays for drugs administered in the doctor’s office).

Under this scenario, the U.S. government would base drug prices for seniors on what its peers in Europe pay, which is almost always much less. Further, the administration has indicated a desire to apply this same methodology to Medicare Part D payments (involving medications sold in pharmacies).

As one might expect, the pharmaceutical industry, which has priced its drugs with impunity, is now responding to governmental intervention with the threat of legal action.

The most effective solution for Congress would be to reverse an existing ban that prevents the government from negotiating prices with drug makers. And yet, even with a majority in the House, the Democrats are unlikely to pass such a bill. There are two reasons for that: (1) Many of them originally voted in favor of this prohibition and (2) the Pharmaceutical Research & Manufacturers of America (“Big Pharma”) has spent $358 billion over the past 20 years to encourage favorable policies. In 2018, elected officials accepted tens of millions of dollars in campaign contributions, seemingly without shame.

Therefore, I predict that regardless of the approach or policy put forth, the 116th Congress will fall short of fulfilling campaign promises to significantly lower drug prices.

2. Single-Payer Coverage (And The Affordable Care Act)

Here’s something no one could have predicted just a few years ago: The issue that seems to have galvanized the electorate at large was the preservation of a key provision in the Affordable Care Act (ACA). Specifically, it was the ACA’s protections for people with preexisting conditions that drove Democratic messaging, attack ads and, ultimately, votes.

Despite a barrage of last-minute GOP ads attempting to blunt the electorate’s memory, midterm voters didn’t forget Republican efforts to “repeal and replace” major portions of Obamacare through reconciliation.

The reality is that Congressional mathematics would have made repeal of this provision impossible, regardless of the election results. Stripping patients of this protection would require 60 votes in the U.S. Senate. Given the limited number of competitive seats up for grabs in 2018, this wasn’t going to happen. Still, that fact didn’t quell voter fear.

Debate in the Democrat-controlled House is now likely to shift in a new direction: Whether to shore up and stabilize the ACA or advance a policy that would provide universal coverage.

Seventy percent of Americans say they support the idea of that would give all citizens access to Medicare coverage (creating either a “Medicare for all” or similar “single payer” system). And, according to a survey in USA Today, more than half of the Democrats vying for House seats in 2018 say they, too, support a Medicare for all approach.

And yet, the chances of Medicare-for-all legislation becoming law in the next two years is approximately 0.00%.

Such legislation would require passage in the Senate and Trump’s signature, neither of which will happen. Furthermore, and of greater long-term significance, the implementation of Medicare for all would result in hundreds of billions of dollars in added costs, requiring higher taxes not just for the highest earners, but for the middle class, as well. That’s a non-starter for any elected official facing a re-election bid in two years.

Although single-payer proponents like Senator Bernie Sanders have claimed Medicare for all (and its many variants) would lead to cost savings, intrinsic in their plans is the belief that government would impose price restrictions on doctors and hospitals. What they don’t acknowledge (at least not publicly) is that providers will offset any decrease in income by performing more tests and services, thus driving up utilization. We can thank our “fee-for-service” payment system and its perverse incentives for that.

So then, is it realistic to expect any Congressional action to affect healthcare coverage before 2020? Maybe.

The Affordable Care Act is growing in popularity despite nearly a decade of heated rhetoric. That’s because it’s achieving many of the objectives that led to its passage.

If Republicans can accept that the ACA is here to stay, Congress could take bipartisan steps to stabilize and improve the health insurance exchanges. Congress could start by committing dollars to “Cost Sharing Reduction” (CSR) payments, which help low-income Americans pay their out-of-pocket deductible requirements. They could also require greater transparency on the exchanges (in terms of quality, service and performance data) so patients can go about choosing the best plans and providers.

3-4. Medicare And Medicaid Funding

Had Republicans exited the midterms with control of both chambers, it’s possible they might have sought to modify one or both of these government-run programs, which together provide coverage for 33% of all Americans.

In 2016, Trump backed a plan to turn Medicaid over to the states with a tight cap on federal funding. Trump has also supported the expansion of health savings accounts (HSAs) in helping “Americans purchase their own coverage” or pay for their Medicare premiums. With Congress split along party lines, neither plan will come to fruition.

5. The Opioid Crisis

In October 2018, not long after survey participants ranked the opioid crisis No. 5 among the most important healthcare issues, Congress passed the bipartisan “Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (or SUPPORT) Act” to boost access to addiction treatment.

With the president’s signature, this legislation brings several legal and regulatory improvements to the fight against America’s opioid epidemic. What it doesn’t contain, however, is funding to cover the massive cost of providing treatment.

Opioid overdose now accounts for more than 70,000 American deaths annually, which has directly attributed to America’s declining life expectancy over the past three years.

If there is a silver lining here, the death rate from opioid addiction seems to be leveling off, although it’s too early to know why. Last month, Geisinger CEO Dr. David Feinberg, offered this fascinating take on the Fixing Healthcare podcast:

I know as an addiction expert, and I say this with the most respect and reverence, even if we did nothing, the opioid problem will get better. The reason … is drugs go in and out of vogue, and the way that it happens is if a lot of people today are dying from opiates, younger kids think the perceived harmfulness of opiates is high. So, as they enter their teenage and young adult years, they will stop experimenting with opiates.

And because higher death rates spark widespread fear, users shift to a new agent of choice. That might explain the recent decrease in usage. On the other hand, the reduction might reflect lower rates of unemployment or success from current addiction-treatment programs. Regardless, the opioid crisis will remain an important political issue in future, especially in the parts of the country most impacted.

6. Abortion (And Women’s Health)

The nomination and confirmation of Brett Kavanaugh to the U.S. Supreme Court took place after the midterm healthcare survey wrapped up. The contentious hearings, viewed by approximately 20% of the country, had a notable impact on female and male voters alike.

With control of the chambers now divided, it’s unlikely that Congress will pass legislation altering current statutes on abortion or other women’s health these issues. At the same time, some states are likely to try to impose major restrictions on a women’s right to choose. These efforts will be challenged in court.

Because the Senate is aligned with the president, we should expect more conservative judges to be appointed and confirmed at the federal level. And if there’s another vacancy on the Supreme Court in the next two years, we should expect the same.

In addition to the abortion debate, the judiciary is likely to decide on restrictions to contraceptives and maternity leave after delivery, as well as other more general health concerns such as work-requirements for Medicaid and the provision of healthcare for undocumented families.

The Most Overlooked Part Of The Healthcare Policy Discussion

Healthcare inflation has risen at almost double the rate of our nation’s Gross Domestic Product (GDP) over the last five decades, not because of insurance or partisan politics, but because of the cost of care delivery.

In a $3.5 trillion industry, there are countless factors contributing to high costs. Among the most significant is the semi-monopolistic control that hospitals, drug companies and specialists enjoy when setting prices. New “miracle” drugs can command prices upward of $100,000 per round of treatment, even when they fail to prolong life by more than a few weeks. Some of the most expensive machines—including multimillion-dollar surgical robots and proton-beam accelerators—have been shown to deliver results no better (and in some cases worse than) traditional, cost-effective approaches.

Our nation’s over-reliance on medical intervention (and, in turn, our failure to embrace the power of prevention) is yet another cost driver. How we value and pay primary care physicians is symbolic of the lack of respect we have for preventive medicine compared to complex, life-saving treatments.

Finally, independent research organizations like the Leapfrog Group have shown, time and again, that low-volume facilities cost more, achieve poorer outcomes and contribute to some 200,000 deaths each year from medical error. When a patient suffers a hospital-acquired complication, the doctor and hospital can often bill insurance companies twice—once for the error and again for the corrective treatment.

As a physician and healthcare commentator, it’s frustrating to hear politicians use healthcare to scare up votes without addressing the industry’s real problems.

Today’s healthcare system is a 19th century cottage industry: it’s fragmented with doctors being paid piecemeal and working without modern technology. As a nation, we could increase healthcare quality and lower prices dramatically if we rallied behind simple changes. It’s time to bring healthcare into the 21st century.

For starters, doctors and hospitals are best equipped to deliver high-quality, highly effective medical care when they’re integrated into larger healthcare systems. In so doing, they’re capable of coordinating patient care and maximizing health.

Second, we can improve efficiency by paying providers for results, not for the volume of services they provide.

Third, to give our patients the convenience, outcomes and timely access they deserve from American healthcare, all doctors and hospitals need to investment in advanced information technology. This kind of technology can allow patients to digitally access their medical records anytime. It gives them the freedom to schedule visits the same way they’d book a flight. And, perhaps most important, technologies such as video and email open the door to better care and communication between patients and physicians. Not enough of these improvements are in place today.

Looking ahead, don’t expect your healthcare to change (or improve) much over the next two years.

That’s because we have confused the disease with the symptom. Rising healthcare premiums and excessive out-of-pocket expenses are not the real problem. They are the result of wasted effort, inefficiency and price-jacking among healthcare’s biggest players: drug companies, hospitals and specialists. Health insurance coverage is essential, but until we as a nation grapple with how care delivery is structured, reimbursed, technologically enabled and led, voters will remain concerned about costs, fearful of losing their coverage and confused about how best to improve healthcare in the future.

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