s Congress and the incoming Trump administration prepare to make health care policy a major focus in the coming months, it’s critical that we have a candid conversation on what’s working, what isn’t, and how asking the right questions is a prerequisite for future reform efforts.
When President Obama signed the Patient Protection and Affordable Care Act in early 2010, he noted that “all of the overheated rhetoric over reform will finally confront the reality of reform.”
“Once this reform is implemented, health insurance exchanges will be created, a competitive marketplace where uninsured people and small businesses will finally be able to purchase affordable, quality insurance,” the president said. The primary question of the ACA debate was addressed: How do we cover more Americans and reduce the number of uninsured?
article continues after advertisement
Despite the rhetoric on both sides of the aisle, the reality is complicated. Before the ACA became law, 15.7 percent of Americans did not have health insurance. Today the rate is 8.6 percent; approximately 20 million Americans directly benefited from exchange plans and the law’s coverage provisions as of 2016, such as the expansion of Medicaid and children staying on their parents’ plans until age 26.
However, insurance coverage doesn’t always equate to high-quality care or patient access to needed medicines. In fact, many Americans are presented with excessive cost sharing in the form of high deductibles, coinsurance, and the use of tiers to determine reimbursement levels. For example, in October it was announced that average premiums for silver health exchange plans are set to increase 22 percent this year.
Conversations about health reform often devolve into ideological debates rather than ones that focus on the appropriate intersection between the marketplace and government. All too often we miss opportunities to focus on the universally held priorities of providing higher quality care and ensuring that patients have access to it.
When Congress debated the Affordable Care Act, a few questions shaped the discussion: How do we ensure that uninsured Americans get health coverage? What is the fastest way to do that? And how can we compel consumers to participate?
Regardless of one’s viewpoint of the existing law, there’s a case to be made that these were the wrong questions for large-scale health care reform. As we look forward, I offer three other questions for consideration:
How do we ensure that individual patients gain access to the highest quality care possible, relevant to their needs?
We need to have a realistic conversation on the difference between coverage and access. Studies have shown that increasing health care coverage leads to lower all-cause mortality rates. Similarly, research has shown that access to medicines reduces health expenditures elsewhere.
However, we shouldn’t be looking at just the big numbers alone. Health care isn’t an all or nothing proposition, but a proactive opportunity to ensure that patients get the high-quality care and innovative treatments they need and deserve. Without access, we can’t make progress with the metric that matters most: reducing the prevalence of chronic disease.
What can be done to simplify health care and make it more consumer-friendly, transparent, and efficient?
We have the tools and technologies to vastly increase transparency for patients, including a better understanding of personalized treatment options and out-of-pocket costs. In nearly every other business sector, from manufacturing to energy, high tech, and transportation, consumers have access to abundant information about the range of options available to them. In the new era of medical invention, that level of useful information is much needed and long overdue.
How do we rethink incentives across the system — with an emphasis on strengthening the competitive marketplace?
We need to get more yield from our investments over time and eventually spend less across the health care system. To accomplish this, the market should continue to lead and deliver disruptive innovations while also recognizing that value goes beyond good business performance. Government is in a position to influence incentives that the market can actively embrace.
One critically important measure is quality, which remains a work in progress between public and private sector stakeholders. In a recent Centers for Medicare and Medicaid Services list of nearly 100 quality measures, 39 percent focused on outcomes, which is a step in the right direction.
At the same time, private payers must actively rethink their focus on one-year actuarial frameworks and begin to view patient outcomes as a basis for success. It’s vital that the system rewards incentives that lead to better long-term results. This will be particularly important as additional innovative treatments are approved for patients.
The path to meaningful improvements won’t be easy. Achieving these shared goals will require collaboration across the health care sector and a commitment to move beyond the ideological (“good vs. bad”) mindset. We must focus on the questions we’re working to answer and find the right level of intersection between the competitive marketplace and government.
The next bite at the apple can help accomplish what we failed to accomplish the first go around. Rhetoric aside, it’s as non-partisan as health care policymaking gets.
Jim Robinson is president of Astellas Americas, a biopharmaceutical company headquartered in Northbrook, Ill.