The Medical Center Hour held a panel Wednesday on healthcare reform post-election, entitled “Morning in America.” Public Health Science Assoc. Prof. Carolyn Engelhard moderated the panel in which B. Rick Mayes, co-director of the University of Richmond’s Healthcare Studies major, and David Toscano, Virginia House of Delegates Democratic leader, spoke about changes with how doctors will be paid and the history and future of the Affordable Care Act.
“[The title] is taken from a 1984 Ronald Reagan re-election campaign, where they introduced the theme ‘Morning in America,’ promoting this image of the U.S. as a hopeful nation moving forward to a better future,” Engelhard said.
Starting in 2019, the federal government will change the way it reimburses physicians under Medicare. In 2015, Congress passed the Medicare Access and CHIP Reauthorization Act, which will shift away from fee-for-service to bundled payment and capitation.
Under fee-for-service, each individual healthcare provider is paid for each service they provide. Under bundled payment, the healthcare system is paid one sum for a procedure such as a hip replacement, and then divides that money among everyone involved. Under capitation, the system is given a certain amount of money to provide care for an individual for a year. The system gets to keep any money left over, but is not reimbursed for any extra costs.
“That’s going to put more pressure on the healthcare system to bring those costs under control,” Mayes said.
However, doctors will never be completely able to control all outcomes, and will take on higher risks. According to Mayes, most will likely join larger practices, either in the form of large healthcare systems like Sentara or Kaiser Permanente, or specialty groups that can afford to accept some losses and still have enough revenue from successful outcomes to balance them out.
“Part of the Affordable Care Act was piloting new ways of paying providers to reward them for quality, and actually incentivize them to think more up-stream, to do more prevention,” Mayes said.
Virginia General Assembly Delegate R. Steven Landes (R-25) also sees prevention as a means of reducing healthcare spending, but said government spending on healthcare and the tricky balance of government and private control of healthcare and health insurance makes it difficult to cover the upfront costs of preventative care.
“Because you have to take care of covering those costs, because of Medicare and Medicaid, and because the government does provide that, it doesn’t leave much flexibility at the state or the federal level, to really do more of the prevention that we could,” Landes said.
While it is unlikely that the Affordable Care Act will be repealed, parts of it may lose their funding, and Virginia is unlikely to accept Medicaid expansion. Virginia, has, however, recently increased the number of people it accepts under existing Medicaid rules. Just last year, a number of people with mental health issues were given Medicaid coverage as disability coverage.
“We’re putting folks in in the least effective way possible,” Toscano said. “We’re putting them in without getting 100 percent back from the government.”
Toscano went on to say that since many people who don’t have insurance end up visiting the Emergency Room, taxpayers end up covering those costs anyway — whether through government reimbursement of the hospitals, or through higher bills of their own through which the hospital tries to recoup its losses.
“You just can’t let the market run amuck, or you won’t be able to control costs,” Toscano said. “So you might see some antitrust stuff out of Trump — who knows? He doesn’t fit very well into the conservative ideology that says let the market work.”
There are a few areas on which Democrats and Republicans seem to agree. But both sides support some sort of measure to reduce pharmaceutical costs and some restrictions on insurance plans.
“People love the insurance regulation reforms,” Mayes said. “They love the getting rid of pre-existing conditions exclusion, lifetime limits on health insurance, annual limits, they like more community rating. That stuff is very popular across the political spectrum.”
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