Stanford Health Policy faculty members Michelle Mello, David Studdert and Laurence Baker discuss repealing the Affordable Care Act (ACA) and how it could affect health coverage in the United States.

Now that the United States has elected a Republican president and Congress, what is likely to happen to the Affordable Care Act (ACA)?

Michelle Mello and David Studdert: Exactly what will happen is unclear at this point, particularly since President-elect Trump’s own position on the ACA seems to be evolving by the day. In an interview on Nov. 11, he said he is interested in keeping some of the key provisions of the law, such as a ban on insurers discriminating on the basis of pre-existing conditions and provisions allowing young people to stay on their parents’ plans until age 26. But his opposition to other provisions, including the cornerstone provision requiring individuals to purchase insurance coverage, likely will remain. At this point, about the only thing one can say with certainty is that substantial change is coming.

Is the ACA likely to be repealed fully, or will some components be spared?

Mello/Studdert: On the campaign trail, President-elect Trump said repeatedly that repealing Obamacare is a priority. House Republicans have said the same. A complete repeal seems unlikely in the short term, though. There’s more opposition to some provisions of the act than to others, and millions of Americans now depend on health insurance coverage made available through the ACA. More likely, Republicans will target certain key elements – the individual mandate, minimum essential coverage rules, the subsidies available to low-income purchasers of health insurance and federal financing arrangements for the Medicaid program. Eliminating all of these features would spell the end of Obamacare as we know it. Eliminating any one of them would seriously threaten its viability, because the ACA’s strategy depends on having all major legs of the stool in place.

What is the legal process for repeal, and what issues would likely arise?

Mello/Studdert: Although Republicans will have a majority in the House and Senate, they fall just short of a filibuster-proof majority (60 votes) in the Senate. This is why a repeal is not likely to occur – at least not straight away – unless several Senate Democrats break ranks in the vote. A more likely scenario is that Republicans will use the budget reconciliation process to make the kind of changes mentioned above. Bills of this kind require only a simple 51-vote majority in the Senate, which they have.

Laurence Baker: Republicans have substantial ability to remove parts of the law under budget reconciliation. They can make changes to aspects of the ACA that involve financial in- and outflows to the federal government, but not other things. Reconciliation thus allows them to make changes to the major things like the mandate – because it involves a tax penalty – the subsidies and Medicaid. But they would not be easily able to repeal things like the exchange structures, guaranteed offers of insurance regardless of health status and other provisions. Guaranteed issue would be a real problem for insurance companies without the mandate, so repealing one but not the other threatens significant disruptions in insurance markets.

Most of the discussions thus far have focused on efforts to repeal the ACA’s expanding coverage aspects, but there are other aspects of the ACA that could be addressed. The ACA set up and funds the Center for Medicare and Medicaid Innovation (CMMI) and Patient-Centered Outcomes Research Institute (PCORI), two organizations that have not been discussed much in the repeal debates and which are seen by some Republicans in a more positive light. The ACA also makes changes to Medicare payments. It seems likely that repeal debates will focus more on coverage and less on these things, but it’s hard to tell at this point.

How will this affect Americans who current receive subsidies for health insurance?

Mello/Studdert: Elimination of the subsidies would have a major effect on the ACA’s core objective to cover the uninsured. By 2017, about 25 million people will have purchased their health insurance on the exchanges set up under the ACA, and about three-quarters of them will receive subsidies to help make premiums affordable. If the subsidies disappear, we should expect that health insurance will become unaffordable for many of these people or no longer look like a good deal. The tax credits and health savings accounts currently being discussed won’t make up for what is lost, and many people who currently have insurance can be expected to drop it. Elimination of the individual mandate will further open the way for this to happen.

Baker: The reality of the health care system is that there are not easily available alternatives to the ACA that would protect coverage and be palatable to broad groups of Republicans. Single-payer, or national health insurance, is a non-starter, so they’d be left with market-oriented reforms, and there are not obvious ways to pursue those without at least some core features of the ACA. Most of the proposals recently put forward for a replacement, including those highlighted by the Trump campaign, like cross-state competition, tax credits for insurance purchase and block granting Medicaid, would not really offer coverage to a large number of the people who would lose it under repeal. So a key question is what alternatives the Republicans come up with. In a similar way, the ACA and its provisions have become increasingly woven into our insurance system. Insurers and employers, among others, have made decisions and investments incorporating the ACA. Undoing those threatens disruptions and political challenges.

Michelle Mello is a professor of law and of health research and policy.

David Studdert is a professor of law and of medicine.

Laurence Baker is a professor of health research and policy, chair of the Department of Health Research and Policy in the School of Medicine and a senior fellow at the Stanford Institute for Economic Policy Research.

As health-care costs climb ever upward, controlling expenses without sacrificing high-quality care becomes increasingly important. Payment systems based on the value of care are emerging as a way to combat rising costs.

Many researchers like Jason Wang, an associate professor of pediatrics and a Stanford Health Policy core faculty member, have found that bundled payment systems may help health-care institutions achieve better value of care.

In a new study in the Journal of the American Medical Association Oncology, Wang and his co-authors show that a value-based bundled payment system is associated with cost containment and improvement in care, even improving chances for survival.

The study examined Taiwan’s bundled pay-for-performance (PFP) system for breast cancer. Instead of the traditional fee-for-service (FFS) system that is typical in the United States — in which every test, surgery and exam is billed individually — this system includes all aspects of treatment in a single established cost, or bundled payment.

Based on guidelines set by Taiwan’s National Health Insurance Administration (NHIA), the pilot program reimbursed health-care institutions’ costs for breast cancer treatment based on the patient’s cancer stage, 0 to IV. Institutions that exceeded the NHIA’s standards received a financial bonus as an incentive for better performance.

The study followed 4,215 patients in the bundled-care system over a five-year period, comparing the quality of their care, the cost of their treatment and the outcomes of their treatment to 12,506 similar patients in the traditional FFS system.

The authors found that patients in the bundled-payment system received better care throughout treatment, were more likely to survive, and contained medical costs over time, compared to their peers in the FFS system.

Costs for patients in the bundled payment system remained about the same throughout the study. However, the cost of treatment for those in the FFS system steadily increased throughout the study period. By the end, even health-care institutions receiving the maximum bonus incentive would incur lower costs than those in the FFS system.

Yet even though their treatment was cheaper, patients in the bundled system experienced better results. Patients using the bundled system had significantly higher survival rates for cancer stages 0 to III, and they were more likely to receive higher quality care based on quality indicators.

This is largely due to the better coordination of care made necessary by the bundled system, according to Wang.

“When you play in an orchestra, the whole group needs to play together, so it plays the right tune,” said Wang. “Focusing on value for the patient and the health-care system forces people to play the same tune.”

Wang believes the lessons learned from Taiwan’s program could be applied in other parts of the world, including the United States, which is currently moving toward bundled cancer care.

Though the U.S. already bundles care for conditions like appendicitis and chemotherapy — in which costs are fairly predictable — many hospital administrators fear that broadening the use of bundled payments for more complex conditions is too risky, financially.

Wang does not share their misgivings.

“People say, ‘We can’t do this for a very complex disease.’ It’s not true,” he said. “When we went outside of the U.S., we started to find systems that work.”

Wang found that when institutions can coordinate care for patients — that is, when a single institution manages all aspects of a patient’s care — the patient is more likely to have better outcomes.

“If institutions take the leadership of providing the infrastructure to coordinate care, they can really deliver better care with the same or lower costs.”

There are benefits for the institutions, too. Right now, because health insurance providers may accept or reject particular costs in an unpredictable way, care institutions never know how much they’re going to get paid for a service. But in a bundled payment system, costs are much more stable and revenue easier to predict.

Considering the benefits, Wang hopes the Taiwan breast cancer study will show institutions in the United States and around the world that bundled payments for cancer can be done on a broad scale.

The value, he said, is worth the risk.

When is the last time you took a good, hard look at your health insurance options? Do you know what changes were made to your plan last year?

If the answer is “no,” you are not alone.

According to a new study by Maria Polyakova, assistant professor of health research and policy and Stanford Health Policy core faculty member, most Medicare Part D enrollees do not change their plans from year to year — even though plans can change drastically.

The study, recently published in the American Economic Journal: Applied, asserts that nudging consumers to re-evaluate their coverage could save them around $500 per year in out of pocket spending and premiums.

What is Medicare Part D?

Implemented in 2006, Part D allows Medicare users to purchase prescription drug coverage. Plans are administered by private insurance companies, but are heavily subsidized and regulated by the federal government. Consumers choose from more than 30 plans in their home state and are able to switch during a yearly open-enrollment period.

About 40 million people in the United States are enrolled in a Part D plan.

But Polyakova finds that “people do not seem to be switching contracts very often. At the same time, the contracts are changing quite dramatically every year.”

Though the study does not examine why consumers failed to switch, the data suggests that changing plans can be costly. Not necessarily a financial cost, but likely one of time or energy.

Thoroughly examining more than 30 plans on a yearly basis can be a burden, and changes are not always easy to detect.

“There are many other features of Part D plans that may change, so even if premiums appear the same, insurers may have changed other parts of coverage, such as deductible levels, co-pays and co-insurance, as well as which drugs are included,” said Polyakova.

Because the Part D market as a whole is dynamic, consumers can lose money even when their plan is stable.

“Even if your specific plan doesn’t change much, it is possible that it is not the best plan anymore because other plans change.”

Consumers tend to stick with the plan they picked when they first signed up. As a result, the study observes that individuals with similar needs may find themselves enrolled in very different plans if they made their first enrollment choices in different years.

This suggests that while most people likely try to pick the best coverage initially, they do not tend to re-evaluate their coverage each year in a way that fits their needs.

How can we improve coverage choices?

Polyakova believes that if the U.S. government were to more actively remind people to re-examine their plans during open enrollment, they could save consumers 20 to 30 percent.

Some researchers worry that improving individual choices and encouraging consumers to update their coverage could negatively affect the insurance market through “adverse selection.”

For example, individuals who are fairly healthy might tend to choose less generous plans than those who are relatively sick. If all those in poorer health end up in one plan, and there are no relatively low-spending enrollees to counteract the risk, the generous plan can become unsustainable.

However, the study finds evidence suggesting that for Part D, reminders to re-examine plans are unlikely to cause issues from adverse selection.

The federal government has implemented risk adjustment policies, or ways to combat the negative effects of adverse selection, that work to keep the market from unraveling. The government provides higher subsidies for sicker patients, pays the majority of patient costs and caps insurers’ profits and losses.

“From the point of view of the government, it seems that it is worthwhile to remind people who are already enrolled to reconsider their choices and potentially explain the differences across plans,” said Polyakova.

As the Affordable Care Act (ACA) changes coverage for Part D plans, reminding enrollees to re-examine their choices will become even more important. The ACA will substantially increase coverage, and plans could change considerably as a result.

What does this mean for the health insurance market?

While the study focuses specifically on Medicare Part D, Polyakova believes these findings likely translate to other areas of health insurance, particularly coverage under the ACA, which has many similar policies.

“The idea that we should remind consumers to re-evaluate plans has already been quite influential in the ACA policy debate,” said Polyakova. “Policymakers are tracking whether consumers are switching plans from one year to the next.”

She argues that in a consumer-driven economy, people must be able to easily make choices between products, in this case health insurance plans, for the market to function. But because choosing takes so much time and plan features are not always transparent, the forces driving the market may become weak.

Educating people about the financial benefits of switching plans could help the insurance market get back on track.

“People should try to reconsider their health risk and their insurance choices during every enrollment period,” Polyakova said. “Because if they don’t, it could have serious financial implications.”

The Supreme Court struck down parts of a Texas law that imposed standards on abortion providers that had the effect of reducing the number of abortion facilities in the state by at least half.  In a 5-3 ruling in which Justice Anthony Kennedy joined the liberal wing of the Court, the justices said the restrictions placed an undue burden on a woman’s constitutional right to seek an abortion. The 2013 law  required all abortion facilities to meet state standards for ambulatory surgical centers (ASCs) and required doctors performing abortions to have admitting privileges at a nearby hospital.

Justice Stephen G. Breyer wrote in the majority opinion, “We conclude that neither of these provisions offers medical benefits sufficient to justify the burdens upon access that each imposes. Each places a substantial obstacle in the path of women seeking a pre-viability abortion, each constitutes an undue burden on abortion access, and each violates the Federal Constitution.”

Michelle Mello, a professor of health research and policy at the Stanford School of Medicine and professor of law at Stanford Law School, as well a core faculty member of Stanford Health Policy, was a signatory to a brief submitted to the Supreme Court by public health academics and the American Public Health Association in support of the abortion providers’ challenge.

What was the main argument of the amici curiae brief submitted to the Supreme Court by public health academics and organizations?

There were two critical factual points that had to be made. First, although the Texas law’s provisions were putatively adopted to benefit women’s health, they actually had no medical benefit.  Second, the law had a rapid, dramatic effect on access to abortion in Texas.  Particularly because in Texas several other restrictions already limited access to abortion and funding for family planning services was scant, this poses a real threat to public health.

Can you say more about why the provisions of the law did not protect women’s health?

The standards were completely unnecessary.  Abortion is an extremely safe procedure; complications rarely occur.  The facilities already had protocols in place to ensure safe transfer to hospitals in the event of an emergency.  But when complications do occur, they usually arise after the woman returns home, so transfer from the facility to the hospital isn’t an issue.  And there’s no reason a woman needs to receive emergency care from the same doctor who performed the abortion. 

Many of the standards for ASCs are simply irrelevant to providing safe abortions.  Many abortions aren’t surgical, they’re medical (chemical).  And standards relating to things like providing general anesthesia, avoiding infections to open wounds, having an advanced heating and air condition system, and having a particular traffic pattern from the operating room to the recovery room just don’t apply.  The state’s argument about protecting women’s health was just a pretext. 

It was a dangerous pretext, in fact, because these were standards that most abortion facilities clearly were not going to be able to meet.  Many hospitals require doctors to admit a minimum number of patients in order to maintain admitting privileges, but abortion is so safe that abortion providers generally can’t do that.  And fitting out a clinic to meet ASCs is prohibitively expensive.  ASCs can afford it because they charge for expensive operations like cosmetic surgeries, hysterectomies, and hernia repairs; abortion providers can’t.

Why do you and the other signatories consider this a public health issue?

More than 60,000 Texas women per year obtain legal abortions.  While we’d all like to see this number go down, you can’t restrict access to abortion while also failing to provide adequate support for other methods of family planning.  History makes it abundantly clear that the result will be greater numbers of women resorting to illegal, unsafe abortions or facing the mental and physical health risks of carrying unwanted pregnancies to term.

Does the Supreme Court’s holding have implications beyond this case?

Yes, because the Court clarified how it will apply the “undue burden” standard of Planned Parenthood v. Casey in future cases.  The majority said that courts must balance “the burdens a law imposes on abortion access” against “the benefits those laws confer.”  The justices also clarified that appellate courts can take a deep dive into the factual evidence about a law’s effects presented earlier in the case.  These holdings collectively make it harder for states to adopt abortion restrictions based on flimsy arguments about how they will benefit women. 

Colorectal cancer is the second leading cause of death from cancer in the United States, after lung cancer, yet many Americans are still loathe to be screened for the disease.

The U.S. Preventive Services Task Force strongly recommended adults ages 50 to 75 to be screened for colon cancer and suggested adults 76 to 85  make individual decisions about whether to be screened, depending on their overall health and prior screening history. The recommendation and several accompanying editorials were published Wednesay in the Journal of the American Medical Association (JAMA).

The independent body of national experts in prevention and evidence-based medicine emphasized colonoscopy is not the only valid test out there. There are multiple screening options available to the one-third of Americans over 50 who have never been screened.

We pose five key questions about the Task Force recommendations to Douglas K. Owens, the Henry J. Kaiser, Jr., Professor of Medicine at Stanford and director of the Center for Health Policy and Center for Primary Care and Outcomes Research. He is an author of the recommendation and was a member of the Task Force when the guidelines were developed.

What is the most significant finding of this final recommendation?

Colorectal cancer is the second leading cause of death from cancer in the United States. The good news is that evidence convincingly shows screening for colorectal cancer works. The Task Force strongly recommends screening adults 50 to 75 for colorectal cancer, as it reduces the risk of dying from the disease. Unfortunately, one-third of people 50 to 75 have never been screened, so we are missing an important opportunity to prevent deaths from colorectal cancer.

There are multiple screening options for colorectal cancer. What are they and how should individuals decide which is best for them?

What really matters is that people get screened. There are several options that are effective, so we recommend that people discuss the options with their clinician. There are direct visualization tests, like colonoscopy, and stool-based tests, like fecal immunochemical testing (FIT). Each test has different strengths and limitations, and people may prefer one approach over another. For example, colonoscopy can be done every 10 years, but FIT testing should be done every year. But the real message is, choose an approach in consultation with your clinician and get screened.

The Task Force found that once adults reach 76 years old, the benefits of screening become smaller and the potential for harm is greater. Why is this and how should older Americans determine which test is best for them?

We recommend individual decision making for patients 76 to 85. The benefits are smaller because a person’s chance of dying of other causes goes up as they get older. The harms are still small but increase with age, primarily because the risks of the potential complications of colonoscopy (bleeding, perforation, and infection) go up with age. Still, some people in this age group will benefit from screening. People most likely to benefit are those who have not been screened before, people who are healthy enough to undergo treatment for CRC should it be found, and people who do not have other diseases or conditions that limit their life expectancy substantially.

Owens explains the Task Force's recommendations to JAMA

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JAMA Network | JAMA | USPSTF Recommendation Statement: Screening for Colorectal Cancer

African-Americans have the highest incidence of and mortality rates from colorectal cancer among all racial and ethnic subgroups. Why are African-Americans more susceptible and does this mean that the screening recommendations differ for them?

The Task Force recognizes the burden that colorectal cancer has on African-Americans, who are at higher risk of being diagnosed with and dying from the disease than other racial/ethnic subgroups. We don’t know why this is — more research is needed in this area. The Task Force did not find enough evidence to conclusively support that making a different recommendation specific to African-Americans would result in a greater net benefit for this population. So our recommendations are intended to apply to all racial/ethnic groups. More robust efforts are needed to ensure that at-risk populations actually receive the screening tests and the follow-up treatments or interventions they need, as people are dying unnecessarily from this disease.

What data did the Task Force use to come to its conclusions?

The Task Force commissioned a comprehensive systematic review of the available evidence on the benefits and harms of colorectal cancer screening. The Task Force also commissioned a modeling study from the Cancer Intervention and Surveillance Modeling Network (CISNET) to help it better understand different screening strategies, such as the optimal age to start or stop screening, and the length of time between screenings. The evidence is convincing that screening reduces the risk of dying from colorectal cancer.

Nancy Lonhart is the calm at the center of the storm for the 70 people working at Stanford Health Policy.