Why It Matters
Republicans have said they want to “repeal and replace” the ACA, but what exactly they intend to do, and how feasible that will be, is still unclear.
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What’s Next for the ACA: An Expert Offers Insights into the Future of Health Reform

By Stephanie Garry Garfunkel | Friday, December 16, 2016
Obama signing the Affordable Care Act

One of the architects of the Affordable Care Act spoke to members of the IHI Leadership Alliance last month about what might happen to health care reform come January.

John McDonough, Professor of Public Health Practice at the Harvard School of Public Health, was pivotal to the passage of universal health care in Massachusetts, which became the model for the Affordable Care Act (ACA).

“No one knows more or has done as much [as McDonough] to contribute to the policy environment,” said Don Berwick, IHI President Emeritus and Senior Fellow. Berwick joined the call with members of the IHI Leadership Alliance, a dynamic collaboration of health care executives working to deliver on the full promise of the IHI Triple Aim.

McDonough said that the questions about what might happen to the ACA can be summarized in two words: “intention” and “uncertainty.” Republicans have said they want to “repeal and replace” the ACA, but what exactly they intend to do, and how feasible that will be, is still unclear.

Here are some of the insights McDonough shared:

  • In January 2016, the House and Senate passed a bill to repeal the ACA that McDonough said might be a preview of their approach in 2017. The bill would have repealed the Medicaid expansion and health care exchanges, but included a two-year delay for when it would take effect, giving them a chance to create a replacement in the meantime. “They seem poised to do that again,” McDonough said, though some Republican leaders are now suggesting a three-year delay.
  • The timeline for similar legislation to repeal the Affordable Care Act, and when it would go into effect, is unclear. It took three and a half years to implement the ACA after its signing in March 2010, and some have speculated it would take longer than the January bill’s two-year delay to craft replacement legislation.
  • The parts of the ACA – and other recent Congressional reforms – that have affected delivery reform, incentivizing health systems to move from volume to value, are likely to stay in place. This includes MACRA, penalties for health care-associated infections and readmissions as well as value-based payment schemes such as bundled payments and Medicare Shared Savings programs. “There’s a lot of evidence that the Republicans like much of that,” McDonough said.
  • So-called “guaranteed issue” — the provision that prevents health insurers from denying coverage for pre-existing conditions — may be scaled back. This is one of the most popular provisions of the ACA, and Republicans have expressed support for it, but their plans involve a more limited version of what the ACA currently requires. Their “guaranteed issue” may only apply to people who can maintain continuous insurance coverage without gaps beyond a set period. That means if you lose your health insurance, your next insurer may be able to deny you coverage on the basis of a pre-existing condition because of the gap in care.
  • All these predictions may change when the Republicans take over on January 20. Starting then, the Trump Administration and Republicans in Congress will be in charge of the existing system, including the health care exchanges, and they’ll want to avoid making changes that might scare away insurance companies and create other dangerous market disruptions, according to McDonough. “The politics will change enormously on January 20, because all of a sudden it’s now the Republican President and Congress’s system,” McDonough said. “As much as they want to blame Democrats, they’ll own it.”

Health care leaders from innovative systems around the country shared their reactions to the election results during the call. For the most part, leaders said they were planning on staying the course, continuing to pursue the Triple Aim and improve care and outcomes for patients.

That’s exactly what McDonough advised systems to do. He also urged health systems to raise their voices in the debate that’s sure to come. He said health systems can play an important role in communicating the real impact that legislative changes to the ACA may have on health systems and patients.

“We’re going to do everything we can to preserve access to great health and lower cost,” added Berwick.

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