Takeaways from a year of health care disruption

By John Rother, President and CEO of the National Coalition on Health Care

With 2018 now underway, the National Coalition on Health Care has been reflecting on the tumult of the past year and what we have learned. There has been so much going on in health care and health policy, much of it negative, that it’s difficult to form a simple assessment of the possible impact going forward. Here are ten significant observations as we reflect back on 2017:

1. The Affordable Care Act’s reforms of individual insurance markets survived, even though weakened by the repeal of the individual mandate and the Administration’s regulatory actions designed to undermine the ACA. Ironically, individually-purchased insurance plans are now even more dependent on public subsidies as more are eligible for premium support.
2. Medicaid not only survived, but emerged politically stronger than ever thanks to the vigorous public debate over “repeal.” The future of health delivery innovation shifted to state Medicaid programs, where varieties of managed care now predominate. The big questions now are the fate of the program in non-expansion states and whether Congress reduces the overall federal support for the program in future budget battles.
3. Health care spending growth overall remained modest, with the notable exception of pharmaceuticals. Although we have seen increased approval of generics at FDA, lawmakers continue to face strong public and purchaser pressure to break the legislative logjam which has, for at least a decade, protected Pharma’s unsustainable pricing practices. Unjustified pricing practices at launch and post-launch price increases will receive increased public scrutiny. Greater transparency will be the likely first step toward a solution.
4. The move from paying for volume to paying for value is now widely supported at the rhetorical level. However, operationalizing these reforms is proving difficult and the Administration has slowed the pace of alternative payment model growth in Medicare. Restarting progress, at CMS and in the marketplace, is essential.
5. Medicare‘s future is increasingly tied to Medicare Advantage (MA), despite recent criticism about narrow networks and transparency as to their quality and composition. Over 50% of new enrollees chose Medicare Advantage last year. It’s increasingly clear that the future of Medicare lies with a well-functioning Medicare Advantage program.
6. Employers continued to limit their own costs by cost-shifting to employees. Without far more impactful payment reforms or significant progress on provider and drug pricing, employers will be forced to keep shifting to high-deductible plans. Access and affordability are now at risk, not just for the uninsured, but for people enrolled in these high-deductible plans. Health coverage alone is no longer an adequate indicator of access or affordability – even from a major employer.
7. Health care organizations consolidated at a rapid pace, presumably to increase their market power. Some mergers, like the CVS purchase of Aetna, have the potential to transform the way health care is delivered by better integrating care. But overall, these mergers threaten to reduce the role of physicians in favor of hospitals and insurers.
8. Health care costs are now dominated by treatments for those with chronic conditions, but our financing and delivery systems have not adapted. The role of social determinants is now better understood, but too few organizations are seriously investing in remedies. Support for prevention and population health initiatives remains weak, despite growing evidence of long-term value.
9. Health care delivery varies greatly across the country, as NCHC’s series of health care summits have demonstrated. Instead of a national system, we are confronting regional systems that are quite distinct and increasingly urbanized. Rural health care is eroding quickly. The role of telehealth and clinics staffed by advanced practice nurses is increasingly important for those distant from major health resources.
10. Regrettably, leadership in confronting all these issues is weak. The Administration and current Congressional Majority have yet to articulate a coherent policy. The Democrats don’t yet have a credible or powerful voice that can mobilize support beyond protection for the status quo. The health sector is divided and concerned with short-term issues. The lure of single payer threatens to monopolize the attention of progressives, while conservatives seem unable to agree amongst themselves as the “replace” efforts demonstrated.

Given these observations, it’s clear that the challenge of moving toward a more affordable, sustainable system that offers good care for all remains. A unifying policy consensus is lacking, so no wholesale solution is likely to prevail. Instead, we may anticipate a more fragmented set of developments in health care.

The question before us – and it is an important one – is whether those developments lead us forward or backward.

Moving a system of this size and complexity forward will require joint action by all those involved in delivering, paying for, and receiving needed care. It will require cooperation by policymakers with very different end goals for American health care. But the National Coalition on Health Care is committed to making progress wherever we can. We challenge leaders of all political stripes and all those with a stake in the future of health care to join us in that effort.