Whether repealing or replacing ACA, let’s get the underlying principles right
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As the President, Secretary Tom Price and Congress work to replace or fix the Affordable Care Act ((ACA), we should debate the underlying principles and get those right. The eventual choices in implementation will be intensely political. Here is a checklist for principles that the legislation should address.

For the people: affordable, adequate healthcare

Access to affordable healthcare for optimists means everyone has health insurance; for pessimists, everyone who can pay for insurance gets it. The appropriate use of access in healthcare means that a person can see the right medical practitioner at the right time and the right place.

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One of the best ways to obtain access is to have health insurance or coverage. Access can also be obtained in a safety net clinic or hospital, such as Federally Qualified Health Center, or county hospital. Legislation should provide access to all citizens, meaning no gaps in the safety net.  Many safety net clinics have no specialists – a gap in the net in need of repair.

 

Access will be improved when payments go to integrated systems of doctors and hospitals, that will pay the right and most cost-effective provider ranging from physicians to nurse practitioners to grand aides. The right place can be email or video  and usually not the emergency department for colds and sore throats.

Affordable must refer to total out of pocket costs — premium plus deductible — not just premium as ACA did.

Those with incomes below the Federal Poverty Level ($11,000 for an individual) should have little to no premium, but a copay for a visit, perhaps $5-10.

Above this level, affordable is considered five percent of income and 10 percent at $44,000.

Currently, the ACA out of pocket cost is $6,449 for a 40-year old nonsmoker, making $22,000; affordable is $1,100 (5 percent) not $6449.

Adequate is tough to define; it is the care everyone wants and needs. The views are divergent — for example, some patients want less care than their doctors prescribe. The discussions must also deal with what this care costs.

Currently, the federal government is not permitted to use cost data in deciding what to cover. This must change. If people can afford more, that’s fine – just like transportation. Some take a bus and some drive expensive cars.  

In this context, it should be the best possible bus that has enough seats and won’t keep breaking down. Increasing access without some basic minimum of care being assured is an empty promise. New legislation should encourage these decisions.

For providers: pay based on quality, and less hassles

Practitioners should be able to provide the best possible care, within the limits of “adequate” as defined above, with salary at their present level, except for those in first five years of practice who can be paid more, plus bonus for quality.

Care should be hassle free, including a well-functioning Electronic Health Record (EHR). Insurance companies are currently required to spend 80 to 85 percent of their premium on medical care.

This requirement should be the same for providers, who now spend only 55 percent in direct care of patients, with the rest wasted on administrative tasks.

The new legislation should consider a well-functioning EHR to be a top priority and spend real money getting there. The savings will be more than recouped.

Legislation should incent formation of integrated health systems, building on our experience with Accountable Care Organizations — the system should receive payment in a way that encourages innovation. Competition should be fostered among systems and across states.

For the U.S. healthcare system: improve cost, quality and life expectancy

Cost and quality must be considered together.

We do not want to reduce cost only to have quality suffer. We waste one third of our healthcare dollars – about $1 trillion per year, with the largest amounts on administrative inefficiency (how many times do you need to be asked your address), overuse and duplication of tests and procedures and high prices such as drugs If we could save just 10 percent of the waste, we could pay for the uninsured.

Here are three ideas:

1. Salary physicians (above), potentially saving $300 billion per year.

2. Help to fund EHR’s so that within 5 years, practitioners and patients reap the improvements in cost and quality. Rand estimates $81 billion in eventual yearly savings;

3. Attack Chronic disease. Reducing readmissions, unnecessary admissions and Emergency Department visits could reduce the cost of chronic care by 10 percent.

The budget for Medicare Home Health is $89 billion per year.  The concept for how and where to care for a patient should be revised.

The U.S. life expectancy is 43rd in the world. We can be in the top 10;  we have the minds and the money can be found with reduced waste. If we get the foundational principles right, no matter what side of the aisle, improved healthcare legislation can help get us there.

Arthur Garson, Jr., MD, MPH, MACC is the director, Health Policy Institute at Texas Medical Center.


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