YAKIMA, Wash. -- Now that Congress has set aside — at least for the moment — Republican plans to repeal the Affordable Care Act and replace it with the American Health Care Act, local and state health care leaders hope legislators will look at ways to improve the existing law so it can better serve patients and providers.
“The health system is very complicated, and improvements require changes in not only insurance reform, but in how care is delivered as well,” said Leanne Berge, CEO of Community Health Plan of Washington, in an email.
While the ACA has dramatically increased the number of Americans with access to health insurance, primarily through the Medicaid expansion (which added more than 600,000 people to the public health program in Washington state), private health insurance plans are still out of reach for many middle-income consumers.
Improving affordability of those plans tops the wish list for health care leaders. But that means stabilizing the exchange marketplaces where Qualified Health Plans are sold.
In Washington state last year, all nine insurers that sell plans on the exchange filed rate increases for 2017, ranging from 7.43 percent to 18.9 percent year over year.
“The common message we hear from our customers is that they want affordable coverage in a market they know they can count on for many years to come,” said a statement from Melanie Coon, senior communications manager for Premera, which logged the 18.9 percent increase.
Stablizing the market will require a more diverse risk pool, where it’s not just older, sicker patients who require the most costly health care.
“Premera supports the work of federal and state lawmakers toward solutions that ensure young, healthy people have strong incentives to purchase coverage, adequately finance subsidized access to care, and a mechanism that makes it possible to better manage risk in the individual market member pools,” Coon’s statement said.
Under the ACA, anyone who makes up to 400 percent of the federal poverty level (about $97,000 for a family of four) is eligible for some level of subsidy to offset the cost of their chosen health plan on the exchange, but the subsidies still aren’t enough to make plans affordable for many.
“Anything Congress could do to improve affordability in premiums. ... People make really difficult choices between affordable premiums and accessible deductibles,” said Rhonda Hauff, chief operating officer at Yakima Neighborhood Health Services.
In high-deductible plans, monthly premiums may be lower, but then patients tend to avoid seeking care altogether because they have to pay out of pocket for services until they reach their deductible, generally several thousand dollars, or more than $10,000 when dependents are included on the plan.
Preserving the Medicaid expansion is also of utmost importance, Hauff said: “I don’t think we can overstate the value that has had for individuals and families, not only primary medical access but also for access to dental care and mental health.”
But while more people have gained coverage, Medicaid reimbursement rates to providers are still notoriously low compared with commercial insurance.
Hospitals would like to see their disproportionate-share hospital funds restored, said Mary Kay Clunies-Ross, vice president of membership and communications for the Washington State Hospital Association.
Disproportionate share hospital payments — DSH — help hospitals that care for a high number of low-income patients. The ACA phases them out by 2020, under the assumption that because more patients would have Medicaid coverage, instead of being uninsured and paying nothing, hospitals would no longer need the extra compensation.
But “Medicaid still doesn’t cover the cost of care,” Clunies-Ross said. “If they were to keep (Medicaid) coverage and restore DSH cuts, that would make it a lot easier to provide care to those patients.”
With Medicaid’s low reimbursement, fewer doctors are willing or able to take on Medicaid patients, particularly complex cases.
“And they’re coming in sicker, still; I think that that’ll be a while before we really see the benefits of expansion play out in terms of improving community health,” Clunies-Ross said.
While requirements for documentation using electronic health records often predate the ACA, or occurred concurrently to the law, physicians hope that lawmakers work to simplify and streamline those regulations going forward.
“Physicians don’t want to get rid of their EHRs; they understand the value, they just want to make sure it works in a way that’s natural to their work flow,” rather than a series of mindless boxes to check off, said Jennifer Hanscom, executive director of the state Medical Association. “It would be great if we could sit down with the folks at (Health and Human Services) in particular to kind of walk through that, and keeping the lens of a physician on all those regulations.”
A big area where documentation regulations appear at odds with the broader transition from fee-for-service to value-based purchasing is in prior authorization, Hanscom said: Why do insurers still require prior authorization, a extra step for patients and doctors, if doctors are already using the best evidence-based guidelines to make decisions about what services the patient needs?
She’s optimistic that new Health and Human Services Secretary Tom Price, a former practicing physician, will be sympathetic to providers’ concerns.
Physicians, hospitals and insurers agree that bringing prescription drug prices under control is another top priority and a major factor in overall affordability of health care.
“We haven’t seen any real attempts at the federal level to rein in the cost of prescription drugs,” Hanscom said.
Soaring drug costs hinder providers’ ability to deliver the best care for their patient, Clunies-Ross said, if the patient can’t afford a certain medication, or if the price suddenly spikes in the middle of treatment.
“It’s certainly part of health care reform and changes that the new administration, if they wanted to ... it would be a good place to work,” she said. “There was a lot of talk during the campaign and after the inauguration about getting better deals for drug prices.”
• Molly Rosbach can be reached at 509-577-7728 or firstname.lastname@example.org.