In this assignment, you will create a Policy Memo that explains and assesses the advantages and challenges of one of the three emerging organizational structures and payment reform approaches. (accountable care organizations, patient-centered medical homes, bundled payment).
Your paper must be about 1,500 words and draw upon and cite at least five high-quality references.
Governing Health (The Politics of Health Policy) *****ebook converter DEMO Watermarks******* Governing Health *****ebook converter DEMO Watermarks******* GOVERNING HEALTH The Politics of Health Policy FIFTH EDITION William G. Weissert and Carol S. Weissert Johns Hopkins University Press Baltimore *****ebook converter DEMO Watermarks******* © 1996, 2002, 2006, 2012, 2019 Johns Hopkins University Press All rights reserved. Published 2019 Printed in the United States of America on acid-free paper 9 8 7 6 5 4 3 2 1 Johns Hopkins University Press 2715 North Charles Street Baltimore, Maryland 21218-4363 www.press.jhu.edu Names: Weissert, William G., author. | Weissert, Carol S., author. Title: Governing health : the politics of health policy / William G. Weissert and Carol S. Weissert. Description: Fifth edition. | Baltimore : Johns Hopkins University Press, 2019. | Includes bibliographical references and index. Identifiers: LCCN 2018039679 | ISBN 9781421428932 (hardcover : alk. paper) | ISBN 1421428938 (hardcover : alk. paper) | ISBN 9781421428949 (pbk. : alk. paper) | ISBN 1421428946 (pbk. : alk. paper) | ISBN 9781421428956 (electronic) | ISBN 1421428954 (electronic) Subjects: | MESH: Health Policy | Politics | United States Classification: LCC RA395.A3 | NLM WA 540 AA1 | DDC 362.10973—dc23 LC record available at https://lccn.loc.gov/2018039679 A catalog record for this book is available from the British Library. Special discounts are available for bulk purchases of this book. For more information, please contact Special Sales at 410-516-6936 or
[email protected]. Johns Hopkins University Press uses environmentally friendly book materials, including recycled text paper that is composed of at least 30 percent post-consumer waste, whenever possible. http://www.press.jhu.edu/ https://lccn.loc.gov/2018039679 *****ebook converter DEMO Watermarks******* Contents Acknowledgments Introduction 1. The Policy Process 2. Congress 3. The Presidency 4. Interest Groups 5. Bureaucracy 6. States and Health Care Reform Conclusion References Index *****ebook converter DEMO Watermarks******* Acknowledgments In the past, our children have been kind enough to accept responsibility for any errors or omissions. When they left the house, we blamed our dog Bailey, but alas, he passed on to dog heaven a couple of years ago, and our new dog, Buddy, is just too sweet and perfect to be responsible for anything but boundless affection and great greetings. Thus we are left with each other. Hence, all errors are the fault of each coauthor, who humbly accepts the blame. *****ebook converter DEMO Watermarks******* Governing Health *****ebook converter DEMO Watermarks******* Introduction It had been a long time coming when in 2010 the Obama administration and a Democratic Congress passed by a single vote in the Senate and by legislative sleight-of-hand in the House a historic reform of US health care, the Affordable Care Act (ACA). The changes leveled the playing field in health insurance by requiring all Americans to buy and all sellers to sell to all comers, mandated that large and mid-sized employers provide insurance or pay fees for government coverage, and ended preexisting condition exclusions in health insurance policies as well as a plethora of other industry abuses that companies indulged in to protect themselves from adverse selection, moral hazard, and an inevitable death spiral if they enrolled too many sick patients. Access to care was expanded by the ACA through these market reforms, through broadened Medicaid coverage in states that chose to accept a generous offer of federal support for expansion, and through state or federal exchanges that sold comprehensive policies at reasonable premiums made affordable by subsidies based upon a sliding scale of income. But the Republicans hated the ACA (which they dubbed Obamacare) in part because of the way the law was passed—namely, by avoiding the necessity of a confirming Senate vote that would have fallen one vote short of ending a fatal filibuster. (A liberal Democratic senator had died and been replaced by a Republican after the bill left the Senate, so there was no chance of passing it there again if the House made too many changes.) But conservatives also hated the law because, in their view, it inappropriately expanded the role of the federal government into areas they believe are better left to the private market or state governments. Thus, when the Republicans took over the House after the 2012 election, they began a series of nearly 60 votes to repeal Obamacare. The votes won a majority in each Republican House time after time, even though President Barack *****ebook converter DEMO Watermarks******* Obama was sure to veto the bill. But while Republicans knew they were shooting legislative blanks, they also thought that the vote might garner favor with supporters without causing much pain to some constituents. Nonetheless, when President Donald J. Trump took office in 2017, supported by Republican control of both houses, the repeal failed because three Republican senators balked. Two could not support the damage it would do to their constituents who were happy with their ACA coverage, and one was offended by the closed-door drafting of the bill that led to the repeal vote. Given the tiny majority the Republicans had in the Senate, the repeal went down in defeat, just one vote short. Still, President Trump vowed to keep his campaign promise to repeal Obamacare, and he set about doing as much as he could with his executive authority. Thus, Congress terminated the ACA mandate that all Americans buy insurance, the president ended some subsidies that made many poor Americans able to afford insurance, and granted states authority to offer less comprehensive and shorter-term policies than called for by the ACA—all of which also served his purpose of undermining public approval and confidence in the ACA. In addition, by delaying announcement of whether insurance carriers will be paid back for subsidies they are required by the law to grant to low-income people, he created uncertainty expected to drive some insurers out of the market. Other orders restricted funds and time for open enrollment and outreach enrollment assistance to eligible people, barred regional office staff from participating in open enrollment events, invited governors to request waivers of ACA requirements, allowed employers to opt out of contraception coverage if they have religious or moral objections, and directed federal agencies to find additional ways to permit sale of insurance that does not meet ACA standards. To appreciate the full potential harm to the ACA of these efforts, it is important to understand one simple reality of insurance: For a company to avoid bankruptcy because too many sick people enroll, it must be careful that people who are not sick also enroll. Those who enroll with a company become its “risk pool.” If the risk pool gets too sick, the company must raise its prices, with the effect that the least sick people now refuse to buy insurance, even as the sickest can’t afford to go without it. Consequently, the pool gets sicker as only those who are sick or very much fear getting sick enroll at high prices. This is called the death spiral of insurance: As *****ebook converter DEMO Watermarks******* rising premiums drive out first the well and then the less sick, the pool becomes sicker and sicker and premiums go higher and higher. The ACA protected insurers against a death spiral by requiring everyone to buy comprehensive policies and by preventing insurers from setting prices based upon medical need. The changes made by President Trump and federal agencies at his direction has had the effect of eroding the strategies designed by law to guarantee that the insurance risk pools include healthy and younger people and are not dominated by sick and older people. The result has been an inevitable shrinking of the risk pool in many counties, a sicker, more expensive group of buyers willing to buy insurance, flight from those markets by insurance companies that fear that costs will exceed premiums, and requests by remaining insurers for much higher premiums. With access to insurance coverage beginning to narrow and the number of uninsured rising again from the historic lows reached following implementation of the ACA, the pool has been becoming sicker as only the sickest patients have been willing to pay the higher premiums. If you are a supporter of health insurance for everyone, this is very bad. If you believe that the federal government had no business usurping the states’ role in health insurance regulation, then these steps that undermine the ACA and may cause it to fail in many counties means less federal overreach. These divergent views generally reflect political alignment: Most Democrats want the ACA preserved and improved; many Republicans want it to shrink, one way or the other. President Trump wants it gone. That is what he promised in his campaign. If Democrats were to regain control of Congress, they might be able to put some fixes back in place, provided President Trump did not veto them —something he would likely do unless Congress offered deals on other administration priorities. Yet come what may with the ACA, there are still significant problems with American health care. Our costs continue to far outstrip those of comparable nations, our drug prices are far higher than those of other countries, and our care intensity varies widely from hospital to hospital, city to city, and state to state, with much of the care rendered proving ineffective and probably wasteful. But there are hopeful signs. Some incentives for improvement were adopted in another new, less salient, law: the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). In a rare instance of both *****ebook converter DEMO Watermarks******* bipartisan cooperation and acceptance by the physician community, Congress passed a major reform of the way Medicare pays physicians and other providers, hoping to move their payment incentives away from volume and toward effective performance. The goal of the law is to ensure that more providers follow best practice guidelines, rendering only care of proven effectiveness for the patient’s condition, reporting diagnoses and treatments to electronic health records systems, innovating while avoiding unnecessary expense, and achieving markers of quality and cost-conscious performance. Meeting standards means earning bonuses. Departure from standards, excessive volume, high cost care, and other unreformed behaviors lead to fines. How tough the performance standards will be and how hard the fines will bite will be greatly influenced by regulations to be written by an executive agency, the Centers for Medicare and Medicaid (CMS). Critics feared that force of the law would be blunted by the Trump administration. Such is the way of American policymaking in health care. What we pay for health care, how much we rely upon market competition versus regulation, how much we accept differences in the quality of health care, how much excessive, unneeded, and potentially harmful care we tolerate and pay for, and how some of us run into financial and other access barriers when we try to get care are all aspects of health policy and are shaped by many forces. These include the president, Congress, federal agencies, physicians, drug companies, unions, hospitals, medical equipment makers, insurance companies, managed care organizations, patient advocates and other interest groups, state legislatures and state bureaucracies, and all of us consumers of health care who demand that we have access to all the care that is available, whether we need it or not. Republicans tend to favor market solutions and fear bureaucratic interference in medical decision making. They worry that an overbearing federal government will create a dependent class. Democrats criticize the market approach as unrealistic, given the many restraints on competition, and worry that it will produce barriers to insurance and care, which will create a divided society consisting of the nonpoor who are in good health and the poor who are in ill health. Policies change between administrations of different partisan persuasion, though frequently ideas from one administration are adopted by another. Republican President George W. Bush won passage of Medicare prescription drug coverage, an idea that had been pushed by his *****ebook converter DEMO Watermarks******* predecessor, Democrat Bill Clinton. President Obama’s ACA adopted market exchanges to sell ACA policies, an idea long favored by Republicans. Or did Republican Senator Marco Rubio (FL), who pushed the state legislature to fund a small health exchange in his home state when he was leader in the of Florida’s House of Representatives, get his idea from the Republican-derided “health alliances” offered in President Bill Clinton’s failed 1994 health insurance plan? US health care policy reflects the complex cultural, political, economic, social, historical, and institutional forces that shape it. This book explores how government makes health policy, including the partisan political forces that influence decisions. Most health care in the United States is delivered by the private sector, but because public policy pays for and regulates so much of this care, health policy is vitally important. Moreover, private payers for health care tend to mimic the payment approaches of public policy, so public policy’s reach extends even farther into the private portion of health care policy—another reason that foes of large government oppose the potential distortions that they fear will result from government insurance. Because so much of health care is outsourced and becomes the income stream of private-sector providers, claims processors, makers of health care products, and others, private interest groups have a huge stake in public policy and find it a good bargain to spend rather lavishly on lobbying and other strategies aimed at influencing public health care policy. Most industrialized countries pay for most of their citizens’ health care publicly. We place more faith in private payment and attendant market competition to reduce prices and improve access and quality. In general, it has not worked, in part because our delivery system restricts competition in a number of ways: Some providers or insurers dominate their markets, many drugs enjoy patent protection, which they are then able