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Tuesday Apr 02, 2019

Trump Administration Rolling the Dice on Health Care

"If you don't like the world you're living in, take a look around you; at least you got friends."
-- Prince

[red dice on gambling table]

Just when you thought Washington, D.C., couldn't get stranger …

On March 25, the administration renewed its assault on the Patient Protection and Affordable Care Act (ACA) via a legal brief(theincidentaleconomist.com) filed with the U.S. Court of Appeals for the Fifth Circuit (New Orleans) that stated, "The Department of Justice has determined that the district court's judgment should be affirmed. Because the United States is not urging that any portion of the district court's judgment be reversed, the government intends to file a brief on the appellees' schedule."

Put more succinctly, that brief from the Department of Justice (DOJ) stated that the Department of Justice would no longer defend any portion of the ACA in Texas et al. v. United States et al. That case was filed by a group of state attorneys general who assert that once Congress eliminated the tax penalty imposed on those who do not obtain health insurance -- the "individual mandate" -- the entire law became unconstitutional, primarily based on a belief that the original Supreme Court decision hinged on Congress' taxing authority. (For more, read this excellent summary(www.kff.org) from the Kaiser Family Foundation.)

In a June 2018 letter to (then) Speaker Paul Ryan,(www.justice.gov) the administration had announced that it would not defend the individual mandate or associated penalties, but it signaled its intent to defend the insurance reforms and patient protections included in the law.

That position changed in the more recent filing. The AAFP quickly responded, noting in a press statement that "the ultimate outcome of this case will determine whether tens of millions of Americans will have access to necessary -- and often lifesaving -- medical care." The AAFP also joined with our Group of Six partners (the American Academy of Pediatrics, American College of Obstetricians and Gynecologists, American College of Physicians, American Osteopathic Association, and American Psychiatric Association) to issue a joint statement(www.groupof6.org) that said, "The DOJ's new position, if accepted by the courts, would endanger not only essential protections for persons with preexisting conditions, but other programs that millions of Americans depend on to ensure their access to affordable health care."

The administration's new stance is deeply concerning from a policy perspective. The ACA is not a singular packaged provision that can be easily extracted from statute. It is a complicated series of policies that have been implemented, revised and built upon since the law's enactment in 2010. Should the ACA be overturned by legislation, administrative action or legal decision, the impact would be felt by all Americans, regardless of how they obtain and finance their health care.

It is true that the ACA remains a flawed law, and there are areas that need immediate and significant reforms. However, the complete dismantling of our nation's health care system via an immediate action, minus a plan for what would come next, is irresponsible. Furthermore, the constant churning of the political discourse is having a negative impact on our health care system and is driving anti-consumer behavior, including consolidation of insurers and hospitals, cost-shifting toward high-deductible insurance products, the selling of junk insurance such as short-term limited-duration plans, and the refusal of states to fully invest in safety-net programs such as Medicaid.

The DOJ announcement, which caught Washington by surprise, signaled an escalation of the ACA repeal battle and launched health care back into the upper echelon of domestic policy issues heading into the 2020 presidential election. Further complicating the situation, the president tweeted on March 26, "The Republican Party will become 'The Party of Healthcare!'" Despite well-documented disagreements among the president's senior staff and some tepid responses from members of his own party, it is clear that the president is interested in pushing the issue of health care to the forefront of the domestic policy debate.

The move is politically risky. Looking back at the 2018 midterm congressional elections, it is clear that health care was a dominant issue in many races, and most of these races were won by Democrats. According to exit polls,(www.nbcnews.com) 41 percent of voters prioritized health care. Among those voters, 75 percent voted for the Democrat in their congressional races. The public's view on who is best positioned to deliver on health care has not changed in 2019. According to a Fox News poll taken March 17-20,(www.foxnews.com) the president's approval rating on health care sits at 37 percent.

An additional calculation that is in play is the fact that the ACA is more popular today than at any point since its enactment. According to the Kaiser Family Foundation March 2019 Tracking Poll,(www.kff.org) the ACA was viewed favorably by 50 percent of respondents and unfavorably by 39 percent. The law remains deeply unpopular with Republicans (17 percent favorable to 75 percent unfavorable), but it is strongly supported by Democrats (80 percent favorable to 10 percent unfavorable) and is above water with independents (45 percent favorable to 41 percent unfavorable).

Finally, the optics are bad for the administration. On the same day the president made his proclamation via Twitter, House Democrats were introducing a bill(www.healthaffairs.org) to stabilize the ACA and lower prescription drug costs, setting up a stark contrast between the two parties on the issue of health care.

It is hard to predict where we go from here. The potential negative impact of an unfavorable ruling by the Fifth Circuit shouldn't be overlooked. Should the court overturn the ACA, we can only hope that it provides a long enough runway to ensure that replacement and supplemental policies can be implemented. It should go without saying that a decision by the court to overturn the ACA would set in motion a policy and political process unlike anything we have experienced in many years.

To paraphrase Cousin Eddie in National Lampoon's Christmas Vacation, the ACA, like the Jelly of the Month Club, is "the gift that keeps on giving."(www.youtube.com)

Wonk Hard: Artificial Intelligence Edition

On March 27, the AAFP, in partnership with the Center for Medicare and Medicaid Innovation (CMMI) and the Laura and John Arnold Foundation, launched the CMS Artificial Intelligence Health Outcomes Challenge. AAFP News has an excellent summary of the announcement.

The challenge is an opportunity for innovators(dev.cmschallenge.com) to demonstrate how artificial intelligence tools, such as deep learning and neural networks, can be used to predict adverse events, as well as unplanned hospital and skilled nursing facility admissions, for potential use by CMMI in testing innovative payment and service delivery models. The challenge prioritizes explainable artificial intelligence solutions to help frontline clinicians understand and trust artificial intelligence-driven data feedback to target scarce resources and improve the quality of care.

According to CMMI, the challenge will last about one year. The launch stage will run from March through June 18. Stage one will run from summer to fall 2019, stage two will run from winter through spring 2020, and the winner will be announced in April 2020.

Posted at 09:10AM Apr 02, 2019 by Shawn Martin

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Shawn Martin, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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