I have a friend at the Vermont Department of Health who studies unintentional injuries and violence as a leading cause of morbidity. She was talking to me the other day about how there is a tendency to overlook the importance of preventative health measures, likely because such policies are the victim of their own success. No one gives the Centers for Disease Control a pat on the back for preventing a seasonal flu outbreak.
I am reminded of her wise words as I consider the new Congress and Administration’s aim to replace the Affordable Care Act (ACA), a policy under which 30 million Americans are insured. It is not always clear what role medical professionals should play in policy decisions. I’ll be the first to admit that I have a minimal background in political science, and just six months of training as a first-year medical student. However, when a major cornerstone of federal healthcare policy is set for change, the climate is ripe for an open debate on health care policy. I feel it is my duty to join others in taking a stand to support the policies I think will protect the health care needs of our patients.
The crux of the healthcare debate lies in a simple question – what is the best way for us, as a nation, to invest in our care?
Kevin Brady, chair of the House Ways and Means Committee, likens the new, proposed policies as providing Americans with a health care “backpack,” chock-full with tools to purchase individualized health care plans, manage spending through tax-free saving plans, and access electronic medical records. He believes your health care is personal and you carry it with you through all stages of your life. It’s also not tied to your job or your financial resources. There is a clear shift in focus towards increasing support of catastrophe plans, as opposed to investing in sustained, preventative measures.
The replacement plan proposed by GOP leaders is summarized in this policy brief. Official forecasts anticipate rising health costs, and reforms to make coverage more affordable are definitely in need. It is in this space that medical professionals must speak up. Is the backpack sustainable, or can other approaches more efficiently provide Americans the care they need?
Discussing Policy at Community Forum
Last month, I organized a Health Justice Community Forum with the Students for a National Health Program and Student National Medical Association, where attendees discussed what they think is important to sustain the health of patients. The group, which included medical students as well as a few attending physicians and community health workers, based these values on a set of statements from a national campaign led by medical students.
Although it may be difficult to persuade Congress that preventative health measures are important, forum attendees clearly voiced how valuable they believe them to be. The ACA currently mandates provisions, such as screening for cancers, immunizations, diet counseling, and screening for mental health conditions. Preventative health measures boost quality of life while, at the same time, reduce the need for costly procedures in the future.
Repealing the ACA would see a doubling in the number of uninsured individuals nationwide if a similar replacement bill is not enacted. In Vermont, repealing the ACA would lead to 35,000 Vermont residents losing coverage. More alarming would be the loss in federal funding of $3 billion by stopping expansion of Medicaid. GOP leaders are quick to claim that Medicaid coverage will be maintained under the replacement plan, yet the net effect of their policies is dependent on how the program is implemented, and responses at the state level. This is because they plan to allocate block grants per state. Theoretically, these grants would at first be enough to cover individuals who were previously covered by Medicaid (133 percent of the poverty line), and adjust for the economic well-being of each state. However, the current plan reduces funding after a few years, to fund only the number of people who would have been eligible before the ACA Medicaid expansion, causing a budget shortfall for a state if they wish to keep everyone insured. These grants would be adjusted for inflation; however, Medicaid, as is, has already done a good job of controlling costs, when compared to alternatives. Between 1990 and 2013, Medicaid spending growth per enrollee was just 0.3 percentage points higher than spending growth for the overall economy, whereas overall health spending growth per enrollee outpaced the growth of the overall economy by 1.1 percentage points. Especially if state programs fail to control spending similarly, a faster inflation rate for medical costs could lead to more potential underfunding. Patients will inevitably lose Medicaid coverage over the next few years, unless states provide additional funds (perhaps by increasing taxes on the middle class, which is contrary to the goals of the GOP).
With their new plan, Republicans will replace high-risk pools for patients with complex care conditions under the ACA with “State Innovation Grants.” The idea is that states can have free rein to address high-risk patient care on their own terms. These grants certainly could be effective for preventative measures in response to state-specific issues. In Vermont, for example, funding could be devoted to counter the heroin epidemic. But it is unclear how the impact of these grants will be measured and monitored.
Moreover, innovations at the state-level are not necessary for diseases that broadly affect our entire nation. Take obesity, for example—an issue that affects millions of Americans from all walks of life. A national epidemic should be addressed by a national response, and preventative services to curb obesity are currently included in the ACA. The federal government is uniquely placed to help implement those measures across all states and should continue to make the obesity epidemic a fundamental priority.
Health Care Reform: What’s the Best Way Forward?
I’ve been corresponding with a consultant from the D.C. area who has been discussing health care policy with Republican leaders. His impression is that these politicians are poised to move forward with their proposed plan, potentially within the next few weeks. Even if there is opposition from Democrats, Republicans will likely get it passed through a budget reconciliation bill (which, ironically, was the same procedural move used in 2010 to help pass the ACA).
Reviewing the plans proposed by the GOP leaders, I am left asking myself how I, as a budding physician, can work in an environment in which policy seems to be so out of step with best practices. Healthcare in the United States needs reform, but repealing the ACA is in more ways a step back, rather than a step forward. A shift towards supporting preventative health measures – as opposed to paying for procedures after the damage has been done – could improve health standards and lower costs. Let’s have a discussion about that.
Acknowledgments to Michael Govan and Tim Copeland.