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Voting on health reform in the 2016 election

The 2016 election stands to determine the fate of health care in America. 

As evidenced in Thursday night’s debate, the Republican presidential candidates don’t agree on much. But they do agree on one thing – ObamaCare must go. Ironically, repealing the Affordable Care Act would halt a major healthcare transformation that candidates from both parties support: the transition to value-based healthcare. 

{mosads}Quietly funded by the Affordable Care Act, value-based healthcare has been sweeping across the United States. A rare political issue where social values and fiscal value aligns, bipartisan support for this movement is evident from its absence in the venomous discourse surrounding the Affordable Care Act. Yet a Republican win in the 2016 election could throw the baby out with the bathwater. 

To understand value-based healthcare, it helps to understand what it is replacing. Traditionally, healthcare has been paid for piecemeal; patient sees doctor, doctor provides a service, doctor gets paid for that service. The problem with this payment model is that it encourages doctors to provide more health care, regardless of cost to patients and taxpayers, quality of care, or results. Alternatively, value-based healthcare takes into account the quality of care provided to patients and encourages more efficient spending. 

To test and promote new models of value-based healthcare, the Affordable Care Act established the Center for Medicare and Medicaid Innovation. The center received 10 years of funding and the authority to improve Medicare and Medicaid programs independently of congressional action. Uninhibited by the political gridlock that often stalls reform efforts, the center has made substantial progress in advancing value-based healthcare.

One example of a value-based healthcare model is accountable care organizations. These are groups of physicians, hospitals, and other health providers that voluntarily come together to take responsibility for the cost and quality of care for their patient population. If they reduce spending while maintaining quality of care for their patients, they have an opportunity to share in savings. 

Does an accountable care organization mean patients lose the ability to choose their doctor? No. Patients retain complete freedom to choose where and when they receive care. In fact, you may be one of the 23 million Americans currently cared for by an accountable care organization and might not even realize it. 

Expansion of accountable care organizations is progressing rapidly with over 700 provider groups participating. Early evaluations of the model have shown modest decreases in spending, with equal or improved performance on quality of care and patient experience measures.  

Since 2012, Medicare accountable care organizations have saved the Centers for Medicare & Medicaid Services (CMS) over $1 billion. Notably, this model has also become a darling of the commercial insurance market with over 500 accountable care contracts now established with private payers. Eventually, the slowing of spending spurred by these models would be passed onto the public through reduced premium growth. 

Though all Republican candidates pledge to repeal the Affordable Care Act, candidates have shown veiled support for value-based health care. Republican presidential candidate John Kasich speaks directly to this issue, “I’d like to replace [the ACA] with a health care system that would be market-driven, that would begin to shift us to quality-based health care rather than quantity-based health care.”   

A nod to the Democrats will likely mean incremental improvements to existing healthcare legislation. Conversely, a Republican ballot may fall a guillotine on the Affordable Care Act. The latter case would return Medicare to a model that encourages volume over value, and put in jeopardy advancements valued by both parties – this is the wrong direction. 

Should a Republican be elected, careful legislation rather than repeal could preserve the architecture of the Affordable Care Act that supports value-based healthcare. In this scenario, acceleration of value-based reforms would be slowed, but not lost altogether. 

For Republican-leaning voters with a stake in health reform, the risk of lost progress may create conflict between casting a ballot based on political allegiance, and one based on health care value. Voters need to hold candidates responsible for providing policy agendas that rise above the political fray, and offer solutions to preserve health system changes already benefiting patients, families, and taxpayers.   

The foray into value-based healthcare since the Affordable Care Act has produced important changes and lessons. With hope, these can act as a buoy for bipartisanship supporting health reform regardless of outcome in the 2016 election.

Colla, Kennedy and Mainor are with the Dartmouth Institute for Health Policy and Clinical Practice.


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