AMA Offers Advice in Wake of ACA Repeal Failure

Last week, Speaker of the House, Paul Ryan, and President Donald Trump decided to pull a proposed bill that would have repealed and replaced certain elements of the Affordable Care Act (ACA).

The bill, the American Health Care Act (AHCA), didn't have enough support in the House to pass a vote on the floor. It would have replaced the subsidies that the ACA provided for low-and-middle-income families with a tax credit, ended the Medicaid expansion program in 2020, and increased the amount insurers can charge older consumers compared to younger ones from three times the amount to five times.

On top of not having enough support in the House, the bill didn't enjoy much popularity outside of politicians. It had a 17 percent approval rating, according to one poll and many medical advocacy groups came out and denounced it. One such group was the AMA, whose president-elect, David Barbe, practicing family physician in Mountain Grove, Mo. called the proposed bill a "step backwards" in an interview with Physicians Practice.

Now that the bill has been pulled, we spoke again with Dr. Barbe on health policy. This time we looked at the lessons to be learned from the AHCA failing, how the ACA can be improved, and how physicians should move forward during this uncertain time.

The following are excerpts from our conversation.

What is the lesson of the AHCA failing?

Listen to those who are most experienced in delivering healthcare and who are closest to the patients. I don't think our perspective on the cautions we raised were given enough credence. Our voice was not alone. We were joined by others on the provider side.

Where does Congress go from here now that the AHCA has been pulled?

I think [any legislation] needs to [include input] from [doctors] and patients. It needs to be bipartisan. If there were criticisms related to the ACA, it was on how it passed in the first place. If we could avoid this kind of situation, the odds are good we'll have a better bill and broader support.

What specific improvements would the AMA like to see to the ACA?

One of the concerns that we've had most recently is the ability to afford the premiums. We need to continue to look at how we structure the tax credits. One of [the AMAs] most serious concerns about the AHCA is that it looked like the tax credit structure was going to change significantly and make it even more difficult for people to afford the premiums. Affordable premiums is one thing. Second, affordability of the benefit design. We're concerned that the high deductibles in some of lower tiered plans, like the bronze plan, are so high that [patients] can't use them. It's essentially self-pay except for catastrophic care.

Another improvement is fixing the "family glitch." It's an oversight in the ACA where family members and children are ineligible to receive tax credits in certain situations, specifically when the primary person in the household is employed but the employer doesn't offer affordable coverage. That needs to be fixed.

Other things across the board, we'd like to see more similarities between how all insurance plans, even employer-sponsored plans, are treated. Each of those groups have a whole set of rules and regulations. Insurance have one. Individual plans have another. Employer-sponsored plans have another. It's confusing to patients. It makes it difficult when an individual switches from one category to another. We believe there is an opportunity to improve the regulations across the insurance industry to make it simpler for patients and physicians.

Are there other health policy initiatives that need addressing in DC by this new administration?

Along the lines of health system reform - we're concerned about the issue of continuous coverage as it was described in the ACHA. The AMA's policy is to require coverage – the so-called individual mandate. Even though in some circles, that's not popular. It's the best way to assure coverage, it's the best way to improve uptake so you get more people into the risk pool, which helps lower costs. As you know, those that took up insurance under the ACA were often older and sicker. That makes the pool more expensive. We didn't get enrollment of a younger, healthier population. Going forward, we need to structure the incentives for individual payment purchases in such a way that we get a broader uptake. We need more people in the pool so it spreads the risk and lowers the costs.

Outside of the reconciliation process, [the AMA has] been very concerned about the so-called IPAB – the independent payment advisory board. It was one of our largest concerns about the ACA. It needs to be repealed. That board can make cuts fairly indiscriminately to Medicare spending if certain thresholds are tripped. It's an almost an otherwise unaccountable body. It's not elected, it offers recommendations. Congress has to either take it or leave it. It's not a good way of controlling healthcare spending in Medicare. [The AMA] strongly advocates for repeal of the IPAB in the ACA. That can be done as a separate standalone bill. We feel we have a lot of support in Congress for that.

What's next for AMA in terms of health policy?

We at the AMA and physicians of this country are optimistic [that] Congress won't stop their efforts to reform the healthcare system. Just because the AHCA didn't go forward, doesn't mean we don't need improvements. We will continue to work with Congress to take this up again, bring in a broad group of stakeholders, and hope they listen the voices of physicians, hospitals, patients, and those who are most affected by this.

Looking at the regulatory burden on physicians, it's very inefficient and expensive. We're optimistic we can work with the administration, [Health and Human Services Secretary Dr. Tom] Price….to reduce the regulatory burden. We're working - and have for a long time -with the insurance industry to reduce the unnecessary prior authorizations and other things that not only stand in the way of good patient care, but are inefficient and expensive.

What is your message to physicians during this uncertain time?

Don't lose hope. The AMA are out there advocating on their behalf for a better healthcare system for physicians and patients. To help improve the care we can give and reduce the interference in the delivery of care.

Second thing is we encourage physicians to do what they've always done: give good patient care. We've done that through professional care, irrespective of the system around us. We've done that through the generations. We physicians will continue to focus on our patients and do what's right for [them], while we work on making the system better.