ACCC Calls for Vigilance Despite Repeal Failure

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.

The discussion included a focus on preserving patient consumer protections, a subject that is near and dear to the ACCC, whose leadership this week urged legislators to maintain protections against benefit limits and the ACA ban on coverage decisions based on pre-existing health conditions, among other ACA protections.

Panelists said that one of hard lessons of the ACA has been how hard it was to get young people to enroll in the coverage plans. Their healthier profiles were expected to balance the risk of enrolling older, sicker people; but the design of the ACA legislation has, in many ways, frustrated that objective. For example, allowing young people to stay on their parents’ plans through the age of 26 has undermined optimal plan recruitment, they said. “You shouldn’t have let them stay on their parents’ plans,” Todd said, adding that removing that privilege would have created a healthier risk pool for the exchanges and brought costs down.

The conversation also touched on drug pricing reform. The panelists said the rising cost of medicine has been a long-running debate that may continue without a near-term solution. “I think drug pricing will continue to be a lot of noise—talk, talk, talk—and not much action,” Patel said. Todd mentioned the oft-raised idea of importing cheaper medications from Canada. He said that would likely not work for long. Canada has a small drug market “the size of New Hampshire’s,” and the Canadians would quickly react by blocking cross border sales to avoid jeopardizing their own pricing and access.

Patel speculated that drug purchases will be incorporated into care models and this may improve the affordability of access. Separately, she said the pressure on physicians to make better value choices in medicine is increasingly out of physicians’ hands because payers are dictating so much of what they do by making the approvals process more and more difficult.

Patel and Todd also discussed the future of the Center for Medicare & Medicaid Innovation (CMMI), which suffered a setback with the demise last year of the Medicare Part B Drug Payment Model, a plan to implement different forms of drug pricing and payment that the oncology community contended involved them in an involuntary national experiment with no say in how it was conducted. Patel said that episode in CMMI’s history was so filled with “political toxicity” that it’s unclear what role CMMI will play going forward as an innovation arm of CMS.

The Oncology Care Model, another offspring of CMMI, has been far more successful, and is undergoing its inaugural year currently. The question was posed by audience member and conference participant Cary Presant, MD, of the City of Hope care network, California, whether CMMI would continue to receive funding. Todd expressed doubts that would happen.

“I think it’s really hard to imagine a reauthorization,” he said. With new leadership at the Department of Health and Human Services and CMS, CMMI’s value will be scrutinized and the outcome of that inspection may not be a vigorous thumbs-up. Certain programs should be cut based on honest assessments that they haven’t worked out, but the tendency, Todd said, is a “hands on the scale” approach to make sure that the programs do work. “But that’s not really the point. It’s also to kill things quickly.”