Jennie Crews, MD
The Republican-led Affordable Care Act (ACA) repeal and replace effort has the potential to be revived, but majority leaders may not want to risk further political capital in a battle that could go against them, speakers said this week at the Association of Community Cancer Centers’ (ACCC) CANCERSCAPE annual conference.
The 3-day event at the Renaissance Washington, DC Downtown Hotel opened Wednesday with lobbying on Capitol Hill prior to wide-ranging discussions covering prominent political and practical management issues surrounding the delivery of cancer care in the United States.
“It’s a critical time to make sure that our voices are heard, and we must ensure that, moving forward, patient protections for access to care and affordable care are preserved. Despite events of recent weeks with the failure of repeal, there are still rumblings about reform and replacement of the ACA,” Jennie Crews, MD, president of the ACCC, said.
The keynote discussion included a postmortem on the repeal plan, which Republicans pulled from consideration last week owing to a failure to obtain sufficient House support for passage. “The bottom line was they didn’t have the votes,” said Dan Todd, JD, of Todd Strategy, a Republican strategist who participated in the panel discussion with Kavita Patel, MD, MS, a policy analyst with The Brookings Institution.
Patel said the Republican support issue may have been blamed on the Freedom Caucus and its objections, but in truth, she said, there were diverse opinions among the Republican legislators, all of which factored into the decision to withdraw the repeal measure.
Further, she said, “When [House Speaker] Paul Ryan said Obamacare was the law of the land for the foreseeable future, I interpreted that as, ‘We’re done. We’re not going to be able to take this up.’”
Patel said that despite Ryan’s assessment last week, there remains time for foes of the ACA to attempt another repeal and replace piece of legislation; and indeed, this week Republicans announced that they had restarted negotiations.
Todd said the failure to gain House support hinged upon a false assumption that the only vote that really mattered was the Senate’s. “I think the challenge was they wrote this bill thinking there’s no way they would vote against an Obamacare repeal. I think that was the wrong calculation.” He said an additional mistake was in structuring the bill to pass the Senate without really heeding the dynamics of satisfying House members. “Those in the House really don’t care much about the Senate.”
President Donald Trump may have a seat at the bargaining table during this process, but his ability to make a genuine contribution as a strategist is doubtful, Patel said. “One thing that’s very clear is that whatever your party is, this is a White House that does not have the capacity to understand either the procedure or the process.”
She said that Ryan has greatly leveraged his political muscle in trying to bring about a replacement legislative package and is now inevitably doing a “mental calculus” on how much more he wants to risk. “His job’s on the line,” and this is going to be a factor in whether the repeal effort moves forward, Patel said.
Simultaneously, Democrats are likely working to entice Republican legislators to accept ACA-modification measures as a compromise rather than a complete overhaul, she said.
The health of health exchange markets was also discussed. Todd said the problem is that the mixture of exchange-covered lives is out of balance with the economics of funding the insurance programs sustainably. This has made it necessary for the government to step in with risk-adjustment payments to subsidize these plans. “Effectively it’s a back-end, unfunded mandate. The big question is, will the Trump administration make those payments the way the Obama administration did. My gut tells me no,” Todd said.
Already, the number of health exchange plans is low across much of the United States, making for a “very unhealthy market.” The more payers that pull out of the market, the less stable it will become, Todd remarked. He said that Trump and other Republicans are aware of this and know it’ll eventually force a compromise, but added that even if legislators act now, it may be too late to save the health exchange system.
Patel added that payers who remain involved undoubtedly are making the argument in Washington, DC, that conditions have made it difficult, if not impossible, for them to plan continued health exchange coverage in 2018. “Patients are probably going to suffer until we see something moving forward,” she said. And as time progresses, it will become increasingly difficult for the political majority to pin the failure of the legislation on the Obama administration. “At some point, the Trump administration will own this,” she said.