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Not surprisingly, the sickest people signed up. The complex mechanisms the ACA established to compensate insurers that attracted particularly costly participants proved inadequate. Insurance carriers found that the new population of previously uninsured customers was more expensive than they expected. Some underpriced their offerings, experienced losses, and began to raise premiums or withdraw from some markets, leaving beneficiaries with fewer choices.
Some states also chose not to expand Medicaid, leaving a substantial group of people without affordable coverage. An optimistic scenario assumes that Republicans are sufficiently dedicated to the goal of broadening access to affordable, good-quality care—with private insurance competition as the preferred model—that they will be willing to hammer out a replacement plan that fixes ACA shortcomings and transitions current beneficiaries to the new structure.
It also assumes that some Democrats are willing to work with them and to accept more Republican-friendly attributes rather than opposing such proposals. Elements of such a structure might include allowing insurance companies more flexibility to offer cheaper plans with more limited benefits, bigger differences in premiums by age, greater reliance on health savings accounts, and some ways of combining insurance pools across state lines.
Some of the Clinton proposals might also appeal to Republicans, including a refundable tax credit for those with high out-of-pocket expenses, limitations on out-of-network charges for care delivered in in-network hospitals, greater price transparency, and relaxation of restrictions on the importation of prescription drugs. None of this would be easy.
A Republican replacement plan would doubtless eliminate both the employer and the individual mandates. Some independent analysts have concluded that the employer mandate has only a marginal impact on coverage but not on costs.
However, some substitute would have to be found for the individual mandate that gave younger, healthy people more incentive to buy coverage and thereby reduce average costs. Republicans will also want to give more flexibility to states, not only in Medicaid but also in using federal money to subsidize purchases of private health insurance. This state flexibility could appeal to some Democrats as well.
Indeed, the ACA moved in this direction in its Section waivers: starting in , states are able to substitute a state-designed structure for the ACA as long as the plan achieved the access, coverage, quality, and cost goals of the ACA. This idea could be expanded in the replacement. Much would depend on the attitude of Republican governors toward Medicaid expansion. However, 19 conservative states did not expand Medicaid eligibility to percent of the federal poverty level FPL , which cost their states tens of millions of dollars and opened up a glaring inequity that developed after the Supreme Court decision made the state Medicaid expansion optional.
Since the replacement for the ACA would no longer be associated with a Democratic administration, some Republican governors might be more willing to accept federal funds to fill this gap and broaden coverage in their states. Another approach would be to provide all states with the option of scaling back the Medicaid expansion threshold from percent to percent of the FPL while providing federally funded premium tax credits and cost-sharing subsidies to those with incomes between and percent of the FPL who enroll in fully federally subsidized exchange plans.
This would assuage concerns about future state responsibility for Medicaid costs and would reduce the numbers of families shifting back and forth between Medicaid and exchange coverage. Beyond these policies, there is a long list of lessons from the ACA experience that should be drawn on to inform any replacement effort. Much as Republicans would like to reduce the costs of premium and cost-sharing subsidies, analysts have suggested that even the levels provided by the ACA were likely to prove inadequate, making exchange policies increasingly unaffordable for middle-income and elderly families.
Of even more importance is the need to take measures to expand and stabilize the insurance offerings whether offered through exchanges or some other marketplace. A number of large for-profit insurers have withdrawn from the exchange marketplaces altogether, while others have reduced the counties in which they are offering coverage. In some areas, plan premiums have increased while deductibles and cost sharing in lower cost plans have soared.
Among the explanations suggested for these trends are that marketplace enrollees are less healthy than expected, enrollment is much smaller overall than projected especially in rural areas , enrollees purchase insurance only when they need expensive care and then stop paying their premiums after treatment, and the revenue redistribution mechanisms failed to operate as planned.
Health insurance carriers have found it difficult to make profits in sparsely populated rural areas with few customers and few providers. ACA exchanges frequently offered limited choices in such areas. Democrats have suggested creating a public option to ensure competition, but Republicans are unlikely to support such a plan and might prefer it if the federal government paid for, through competitive bids, a private plan that would offer insurance in counties with no or few exchange offerings.
Until the marketplaces for subsidized insurance stabilize, insurers need to be more comfortable with the accuracy, predictability, and adequacy of the new risk adjustment system. The United States devotes an extraordinary 18 percent of its GDP to health care—a substantially larger fraction than other advanced countries with modern health care systems. For several decades, health spending per capita grew faster than most other spending and seemed likely to push the fraction of economic resources devoted to health care ever higher—to 20 percent and beyond—squeezing competing needs in public and private budgets, including investments in young people.
However, recently, health spending slowed markedly. From to , Medicare spending rose by 1. The causes of the recent spending slowdown are the subject of a lively debate. Even without election-related disruption in the health sector, spending growth is expected to accelerate. Per capita NHE are projected to rise 4. When looking at total, rather than per capita, health care spending, demographic trends will exacerbate the situation. While the under population will be growing by 0.
The lull in new expensive medical innovations seems to be coming to an end. In addition, provider consolidation hospital, nursing home, and home health agency mergers , acquisitions of insurance companies by other insurers, and the purchase of physician groups by hospitals threaten to reduce what little effective competition exists in the health care sector.
Faced with the prospect of rapid health care spending growth, the new administration should lay out its view on the seriousness of the challenge and how it proposes to address it. It will have to make clear what the ACA substitute will do to replace the health spending reductions. The ACA contains initiatives such as the Cadillac tax, Medical Loss Ratio limits, and premium rate reviews that are intended to dampen expenditure growth by private plans.
What measures would replace these? It cut payments to most institutional providers and to Medicare Advantage plans, initiated multiple demonstrations and pilot programs to test various cost-reduction approaches, and established the Innovation Center within the Centers for Medicare and Medicaid Services to explore new payment methods for government programs and a nonprofit Patient-Centered Outcomes Research Institute to sponsor research on cost reductions and improved care delivery.
Unlike other components of the federal budget except Social Security, Medicare has no legal authority to run a deficit in the Trust Fund and would have to cut spending. Moderating the growth of spending of the physician and drug components of Medicare Part B and Part D is also important.
Under current law, general revenues automatically cover any difference between spending in parts B and D and premiums collected, which increases the federal deficit. With total Part B and Part D spending projected to rise by an average of 7. Over the next two decades, parts B and D expenditures are projected to grow by 0. The new administration and Congress should address the future of Medicare and not wait until HI trust fund depletion forces hasty action. Doing so will permit a wider range of solutions to be considered, solutions that can distribute the burden across more stakeholders and generations.
Furthermore, significant policy modifications to Medicare and Social Security must be phased in gradually to allow affected individuals, businesses, and institutions adequate time to adjust. However, Medicare, perhaps even more than Social Security, is the third rail of American politics. Moreover, older people tend to show up at the polls.
Such policies include transforming Medicare into a system of premium supports in which beneficiaries receive a government subsidy voucher that enables them to purchase insurance through an exchange; raising the age at which Medicare is available from 65 to the age at which unreduced Social Security benefits are available or even higher ; increasing parts B and D premiums; increasing deductibles and cost sharing; moving to new payment mechanisms such as reference pricing, and episode-, bundled-, or value-based payments; limiting payments for expensive pharmaceuticals; and raising Medicare HI payroll taxes.
Any candidate with a plan for moving Medicare to sustainable solvency risks scaring older people and being demonized by the other side. Hence, both presidential candidates promised to preserve Medicare, and one argued for popular but inadequate policies compared to the actual need, such as relaxing limitations on the importation of drugs and allowing the government to negotiate prices with drug manufacturers. It seems unlikely that Medicare solvency will be an early priority for the Trump administration, although Speaker Ryan, who has controversial ideas about moving Medicare to a premium support model, has said that he wants to address the issue.
Congress has some experience with bipartisan cooperation on health care issues—for example, in replacing the defunct Sustainable Growth Rate formula with the new MACRA payment system that focuses on value rather than volume of health services.
The next president and the new Congress will have to address other health policy issues as well, including unhealthful food, drug abuse, violence, and other nonmedical factors that impact health; health disparities between affluent and low-income populations; new epidemics and drug-resistant pathogens; and biomedical innovation.
But the issues in this chapter—how to improve the ACA, how to control rising health spending, and how to preserve Medicare for the growing elderly population—should be the focus of policymakers in The Intergenerational Report forecasts that Commonwealth spending on health is projected to grow from 4.
This growth will be driven largely by non-demographic factors: higher incomes which drive consumption , health sector wage increases and technological change.
This means that keeping health spending efficient and sustainable over the period will be a key challenge. Proposals to increase patient out-of-pocket costs, however, raise concerns that high costs deter people from seeking needed health care. Patient out-of-pocket costs account for around 20 per cent of overall health expenditure —a rate close to the OECD average, but considerably higher than New Zealand and the United Kingdom.
According to the Australian Bureau of Statistics , nationally around five per cent of people who needed to see a general practitioner GP , delayed or did not go due to cost. In some regions the rate was almost twice as high. Doctor groups such as the Australian Medical Association warn that the freeze is unsustainable and will force doctors to abandon bulk billing and pass costs on to patients.
So far, the national bulk billing statistics show bulk billing rates for GPs remain high. Nevertheless, reports of GPs abandoning bulk billing and patients attending emergency departments for GP-treatable conditions are emerging. It can move to disallow the regulations that specify the fees for Medicare services. But disallowance would revive the previous regulation which specifies fees that have themselves been frozen at the same level.
A further complication is that the regulation itself has a finite life— expiring after 12 months and 15 sitting days. Another challenge will be addressing the rise of chronic disease. A greater emphasis on prevention has also been urged. One option that has been suggested is a sugar tax.
In , Mexico imposed a tax on sugary drinks and other countries, including the United Kingdom UK , have begun to follow. Early evidence suggests the Mexican tax has reduced soft drink consumption, but evidence of impacts on weight is yet to emerge. Meanwhile, initiatives to improve efficiency and reduce wastage in the health system continue.
The Medicare Benefits Schedule Review Taskforce is reviewing the 5, Medicare funded services against best clinical practice and removing services for which the evidence base is poor. However, in the current political climate any changes to Medicare are likely to face considerable scrutiny, particularly proposals for further deletions. Reforms to private health insurance may come before the Parliament, following the recent consultation process.
Improving consumer value and providing better product information are likely to be a major focus for the Government.
Meanwhile, insurers will be keenly pursuing policies that address their cost pressures, such as reforming the pricing of prostheses. However, proposals for private health insurers to play a greater role in primary care—such as in chronic disease management —could be contentious. Health measures from the —17 Budget will also need to be considered. This includes the proposal to replace the means-tested Child Dental Benefits Schedule funded through Medicare, with a new state-run public dental scheme to be established under a National Partnership Agreement with the states and territories.
Legislation to enact this was introduced in May but lapsed when Parliament was dissolved. In addition, previously presented but unpassed measures from earlier budgets, such as the —15 budget proposal for a single Medicare Safety Net may be re-submitted. This legislation was introduced in , but lapsed at prorogation. Providing accessible and affordable health care to residents of rural and regional areas remains a high priority for many policy makers.
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WebDec 16, · The healthcare industry has six big challenges ahead in rightsizing after the telehealth explosion; adjusting to changing Estimated Reading Time: 10 mins. WebOct 27, · While some healthcare systems are opting to make their service prices accessible – resulting in benefits like a reduction in patient confusion and surprise billing . The problem: Perhaps the most pressing issue in health care currently is the high cost of care. More than 45% of American adults say it’s difficult to afford health care, according to a survey by the Kaiser Family Foundation, and more than 40% have medical debt. The cost of health care changes people’s behavior, with m See more.