Top 5 Things Conservatives Got in Health Reform

[Greenbeard]

It's worth pointing out once in a while some of what the right got out of health reform--those shifts that take the system in the direction they'd like to see it go. Making top-anything lists always involves a judgment call and there are cases to made for this or that other provision topping the list, but I'd say the top five things conservatives got out of reform are:

1. Movement toward high deductible health plans
2. Pressure to pare or eliminate state benefit mandates
3. Interstate health insurance sales
4. Small business pools, along with the option for employee choice
5. Malpractice liability reform grants to states

A closer look at those:

Movement toward high deductible health plans

Many conservative-minded folks seem eager for a health system in which consumers have more “skin in the game” due to enrollment in high-deductible plans. Obviously HDHPs that can be paired with a Health Savings Account already exist and will continue to exist. But the ACA gives them a little boost (not least by explicitly tying the ACA's numerical contours to the numbers governing the GOP-passed legislation that created the HDHP-HSA system in the first place).

In the individual market (which will be mostly the exchange market) for folks without insurance through their job, high deductibles are likely to be pretty common. KFF commissioned three actuarial firms to estimate what deductibles will look like for plans in the exchanges:

In the group markets for employer-sponsored coverage (where most people currently do and will continue to get their insurance), the limitless tax exclusion for health benefits has encouraged more generous, lower premium plans. However, the ACA caps that exclusion, giving employers a strong incentive to keep plan costs below that threshold. And, as Mercer's recent employer survey found, employers have noticed:

Still, the provision that concerns the most employers is the excise tax on high-cost plans – nearly half say it’s a “significant” or “very significant” concern (Fig. 3). [...]

Nearly all the rest are determined to avoid the tax if they can: 21% say they “will do whatever is necessary to bring cost below the threshold amounts,” and 36% say they will attempt to bring the cost below the threshold amounts, acknowledging that “it may not be possible.” Only 4% will take no action to avoid the tax.

Aside from wellness programs, one of the best ways to try and keep costs below that threshold (and beneath the threshold set by the law's affordability requirements) is to play up high-deductible plans for employees:

As employers look ahead, one worry is the excise tax. Effective in 2018, a 40 percent tax will be applied to any of a health plan’s total value that exceeds the premium threshold—$10,200 for individual coverage or $27,500 for family coverage.

But Jay Savan, a senior consultant at Towers Watson, says other economic constraints just a few years off will be more influential than the excise tax in encouraging employers to consider a high-deductible plan.

Beginning in 2014, once the health insurance exchanges are established, employers will have an incentive to keep employees’ premium contributions below 9.5 percent of their adjusted gross income if workers earn less than 400 percent of the federal poverty level, Savan says. Otherwise, the employer will have to pay a penalty—typically $3,000 annually per such employee who receives coverage through a health exchange—for surpassing that premium ceiling. [...]

“The plans that are most likely to allow the employer to stay under that [premium] threshold are going to be high-deductible health plans,” Savan says. “Whether they are HSA-compatible or not, it’s going to be those plans, by virtue of simple mathematics.”

Aside from that, exchanges are required to offer catastrophic plans (meaning plans that have less than a 60% actuarial value) to consumers under age 30 or those who can't find affordable coverage.

Pressure to pare or eliminate state benefit mandates

Exchange plans must meet baseline benefit standards. A draft of those standards is expected to be released soon for public comment; however, the group charged with providing recommendations as to what those standards should look like issued its opinion two months ago. Their suggestion is to keep it limited (HHS "should make it a priority to keep premiums reasonable, even if that means allowing plans to be less comprehensive, counseled the committee of the National Academy of Science’s Institute of Medicine (IOM).")

However, state benefit mandates on exchange plans in excess of those baseline standards will have to be paid for by the state government. Since state governments will, for the first time, directly feel the costs of insurance benefit mandates, there will be a pressure not only to cease tacking on new mandates but also to re-examine the ones they already have on the books.

States May Yet Regret Their Many Mandates

Under the health care reform law, though, any coverage mandated by a state that is not included under the federal government’s definition of essential services will have to be paid for by the states themselves when it’s provided to someone covered by a health plan offered through the exchange. Industry analysts and other keen observers say that provision could trigger a sharp backlash among cash-strapped states against mandated benefits, influencing debates about adding new mandates or inspiring discussions about stripping existing ones from the law books.

Faced with a legislative proposal to mandate coverage of breast ultrasound screenings, breast MRIs, and breast thermography, adding to the 49 mandates already written into Connecticut law, the lobbyist for the Connecticut Association of Health Plans noted that the new federal rule should force legislators to evaluate the added cost of this kind of coverage — and then kick it loose.

“The policy considerations have changed significantly in the wake of federal health reform,” says lobbyist Keith Stover, a lawyer at Robinson & Cole. It used to be that legislators would consider new mandates without any consideration of who winds up paying. Now, he says, “there will be a price for this.”

The state is not likely to add services that aren’t on the federal list because it would have to pay directly for them, he says.

But with most states finding their current spending plans already far too large to digest, adding new costs to the menu may not fly.

“I do think the states are going to change the laws,” says Linda Blumberg, PhD, a senior fellow at the Urban Institute. “In the past, these mandate costs have been spread broadly across those who are insured.” But with the economy flagging and states slashing budgets from coast to coast, “I don’t think the states are looking for more things that they have to fund for health care. My guess is that the vast majority of states will lower the benefit mandates as a consequence.”

Interstate health insurance sales

There are a few avenues to allowing out-of-state plans into state exchanges to allow more options for consumers and potentially stimulate price competition between insurers.

• Multi-state plans. This is the surefire one, as every state will ultimately have multiple nationally-sold plans introduced into its individual market. Health insurance plans that want to sell in multiple states will go through the same process they go through now if they want to participate in the Federal Employees Health Benefits Plan, the program through which members of Congress currently get coverage. In practice, this means that consumers will have access, if they wish, to exactly the same kind of system of competing private plans that serves federal employees and federally elected officials (an idea popular in the rhetoric on both sides). It also means, of course, new options and more competition in state insurance markets.
• Interstate health care choice compacts. The ACA paves the way for states to voluntarily enter into compacts that would allow health plans to be offered in all participating states.
• Multi-state exchanges. If states choose to, they can actually merge their exchanges so that their individual health insurance markets stretch across multiple states.

If the goal is to offer consumers more options than currently exist in their states, that will be achieved.

Small business pools, along with the option for employee choice

A common refrain from both sides of the aisle has been that it should be easier for small businesses to access coverage options for their employees. Enter the SHOP Exchange concept (based in large part on concepts pioneered in ruby red Utah):

Beginning in 2014, Exchanges will also operate a Small Business Health Options Program – or SHOP – that offers small businesses and their employees new choices. Through the SHOP, employers can offer employees a variety of Qualified Health Plans (QHPs), and their employees can choose the plans that fit their needs and their budget.

SHOPs can help your small business by:

Simplifying Choices. SHOPs will provide side-by-side comparisons of Qualified Health Plans, their benefits, premiums, and quality.

Expanding Employee Options. SHOPs will enable you to offer your employees a choice of Qualified Health Plans from several insurers, much as large employers can.

Preserving Employer Control. You will be able to decide whether and when to participate in SHOP. You will be able to choose your own level of contribution toward your employees’ coverage, and make a single monthly payment via SHOP rather than to multiple plans.

Lowering your costs. SHOP can save your business money by spreading insurers’ administrative costs across more employers. In addition, your business may be eligible for small business tax credits when you offer health coverage for your employees through a SHOP. [...]

How will a SHOP make it easier for my small business to offer health care coverage to my employees?

A SHOP will reduce the burden and costs of enrolling your employees in small group plans, and give you many of the cost advantages and choices enjoyed by large businesses today. SHOP will do the work for you of finding qualified health plans, getting information on their price and benefits, enrolling your employees, and consolidating billing. You choose what share of the premium cost to cover. And, depending on the Exchange in your State, you choose which qualified health plans to offer your employees.

The design of SHOP exchanges is ultimately a state prerogative. They can place choice primarily in the hands of the small business owner, allowing him to offer a select slate of plans to employees from the newly organized marketplace. An alternative design would look more like Utah's small business exchange, which uses an employee choice model. In that model, employers specify a defined contribution toward employee health expenses, and the employee takes that contribution into the Exchange and puts it toward the plan of his choice (paying the difference between the plan's premium costs and his employer's contribution himself).

Malpractice liability reform grants to states

This one was a first (federal) step on the prickly issue currently dividing the GOP as to whether tort law itself can or should be federalized. The ACA offers "grants to States for the development, implementation, and evaluation of alternatives to current tort litigation," using language that's been floating around GOP circles for years, from Mike Enzi's health reform legislation, to Paul Ryan's Roadmap, to the Republican Study Committee bill (Herman Cain-endorsed!) to the Burr-Coburn/Ryan-Nunes Patient Choice Act.

The idea, of course, is to offer states carrots to get innovative and tackle reform of their state tort laws themselves.

So we're looking at a higher prevalence of high-deductible plans, fewer state benefit mandates, access to more plans than currently operate in states' insurance markets, an easier time connecting small businesses and their employees to health insurance (with the option of offering employers greater predictability regarding costs, and employees more control over their plan choices), and a vehicle for spurring state-level innovation around tort reform. Wins for conservative rhetoric and, indeed, their policy agenda, assuming their agenda at least loosely aligns with the rhetoric.

 

[dblack]

Greenbeard, while I appreciate the sales pitch, you're never going to understand what we want: the right to deal with our health care, and our health insurance, ourselves - free from the 'plans' of the state and their corporate 'collaborators'.

 

[Greenbeard]

Now that the Republican presidential field seems to have a clear frontrunner, it's also worth looking at how "Newt's solutions" find support in the ACA. Aside from the points already raised in the OP, let's look at a few of Gingrich's suggestions.

Cover the sickest with a High Risk Pool set up by each state to cover the uninsured who have become too sick to buy health insurance.

This idea was implemented under the ACA a year and a half ago on a time-limited basis (until 2014). While there have been successes there (Mom with cancer: "I Want to Apologize to Obama") ultimately the experiment is confirming what was already pretty clear: high-risk pools are not a viable long-term solution to the problem of the uninsured. But they're currently getting their shot in every state.

Protect consumers by reinforcing laws which prohibit insurers from cancelling or charging discriminatory rate increases to those who become sick while insured.

The consumer protections in the ACA are probably its most well-known piece so for this one it suffices to say: check.

Reward quality care by changing the Medicare and Medicaid reimbursement models to take into account the quality of the care delivered and incentivizing beneficiaries to seek out facilities that deliver the best care at the lowest costs.

Value-based purchasing in Medicare is on the rise these days:

Today, January 13, 2011, the Centers for Medicare & Medicaid Services (CMS) published a proposed rule that would reward hospitals for providing safe and high quality patient care. The proposed rule, required under Section 3001 of the Patient Protection and Affordable Care Act, would provide higher payments to hospitals that perform well on certain quality measures relating to both clinical process and patient experience of care.​

And the flip side of paying more for better care, of course, is paying less for shoddy care:

In addition, the law includes a new hospital readmission policy to address the fact that nearly 20% of Medicare patients are readmitted within 30 days after a hospital discharge and that lack of coordination in “handoffs” such as hospital discharges has been identified as a particular problem in the health care system overall. More than half of these readmitted patients have not seen their physician between discharge and readmission, and a recent study suggests that better coordination of care can reduce readmission rates for major chronic illness.5 The policy provides $500 million over 5 years to manage care for 30 days after hospital discharge and also imposes payment penalties on hospitals with high risk-adjusted readmission rates for certain conditions.​

And there's now a major push for accountable care:

The release yesterday of the regulation to launch the Medicare Shared Savings Program (MSSP) marks an important moment in the development of Accountable Care Organizations (ACOs). This is not only because of the substantial revisions made in response to concerns about the draft regulation, but also because it comes amid a range of other public and private initiatives that are expanding the adoption of accountable care payment systems.​

Reward health and wellness by giving health plans, employers, Medicare, and Medicaid more latitude to design benefits to encourage, incentivize, and reward healthy behaviors.

Wellness provisions certainly made it into the ACA:

Among the few areas of bipartisan agreement in the new Patient Protection and Affordable Care Act (PPACA; P.L. 111‐148) are measures aimed at constraining the growth trend in medical treatment spending and costs through health and wellness promotion and prevention initiatives. [...]

Starting January 1, 2014, the PPACA enhances such wellness discounts by permitting group health plans to give reductions of up to 30% of the cost of premiums to employees who participate in such wellness programs. This may be expanded to 50% subject to the discretion of the Secretary of HHS.10

Employers offering wellness discounts must ensure that such programs are voluntary, are not employed in a discriminatory manner―i.e., the program cannot be “a subterfuge for discriminating based on a health status factor,” and give eligible individuals the opportunity to qualify for the discount at least once a year. Additionally, there must be reasonable alternative standards for obtaining the reward (i.e., so that an employee who suffers from obesity due to a non‐treatable thyroid condition can still meet other wellness benchmarks to qualify.) Certain small employers will be eligible for federal grant monies to help launch such wellness programs starting in 2011.11

The PPACA also authorizes a 2014 pilot program testing wellness discounts in ten states’ individual insurance markets. ​

And for Medicaid beneficiaries:

Section 4108 of the Patient Protection and Affordable Care Act (Pub. L. 111-148) (The Affordable Care Act) authorizes grants to States to provide incentives to Medicaid beneficiaries of all ages who participate in prevention programs and demonstrate changes in health risk and outcomes, including the adoption of healthy behaviors. ​

And Medicare got some attention on the wellness front, as well:

The ACA makes changes to Medicare coverage for preventive care services. [...]

In addition to the Welcome to Medicare exam, starting on January 1, 2011, Medicare will cover an annual wellness visit and accompanying personalized prevention plan for all beneficiaries. The visit and personalized prevention plan will be free.​

As well as community-based wellness initiatives to tackle health disparities:

The new national health reform law, the Affordable Care Act, authorized an innovative program to help local communities address racial and ethnic health disparities and reduce chronic diseases by promoting healthy living and tackling the social and economic causes of poor health. These grants are the major provision in the law designed to address the root causes of health disparities. They provide an important opportunity to engage community members in devising solutions that improve their lives. ​

Stop health care fraud by moving from a paper-based system to an electronic one.

The major shift away from a paper-based system that's currently happening is more directly an effect of the HITECH Act of 2009, though the ACA does implicitly assume that transition is happening in many ways.

But beyond that, CMS is indeed starting to use technology to attack fraud head-on:

On the heels of the White House launch of the Campaign to Cut Waste - an administration wide initiative to crack down on waste, fraud and abuse, the Centers for Medicare & Medicaid Services (CMS) announced today that starting July 1, [2011] it will begin using innovative predictive modeling technology to fight Medicare fraud. Similar to technology used by credit card companies, predictive modeling helps identify potentially fraudulent Medicare claims on a nationwide basis, and help stop fraudulent claims before they are paid. This initiative builds on the new anti-fraud tools and resources provided by the Affordable Care Act that are helping move CMS beyond its former “pay & chase” recovery operations to an approach that focuses on preventing fraud and abuse before payment is made.​

Speed medical breakthroughs to patients by reforming the Food and Drug Administration.

An example of a step forward on that front from the ACA:

The Patient Protection and Affordable Care Act (PPAC Act), signed into law by President Obama on March 23, 2010, amends the Public Health Service Act (PHS Act) to create an abbreviated approval pathway for biological products that are demonstrated to be “highly similar” (biosimilar) to or “interchangeable” with an FDA-approved biological product. These new statutory provisions also may be referred to as the Biologics Price Competition and Innovation Act of 2009 (BPCI Act). [...] The BPCI Act aligns with the FDA’s longstanding policy of permitting appropriate reliance on what is already known about a drug, thereby saving time and resources and avoiding unnecessary duplication of human or animal testing.​

Inform patients and consumers of price and quality so they can make informed choices about how to spend their money on care. Patients have the right to know this information, but finding it is virtually impossible.

Greater price transparency among providers:

Additionally, with the enactment of the Patient Protection and Affordable Care Act (PPACA) in 2010, hospitals operating in the United States are required annually to make public and update a list of their hospital’s standard charges for items and services provided by the hospital.​

Greater price and quality transparency among insurers:

The Affordable Care Act further requires each Exchange to rate health plans on quality and price and make the ratings available for consumers on the internet portal.​

 

[dblack]

Yup. Same shit, different party.