Government and Health Care

Can we fix the Affordable Care Act?

August 29, 2017
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Don’t like the prospects for fixing the Affordable Care Act? Repeal and replace somehow didn’t work. Unilateral political action doesn’t seem to be in the cards anymore. Local leaders have not distinguished themselves in addressing real health care concerns. What can be done?

It seems that too much current attention is being given to the insurance aspects of the ACA. This is natural since the act didn’t really address care, just financial coverage.

Tinkering with insurance is a nightmare that causes one to encounter special interest groups clamoring for their share of the pie. There are those who want to get paid, and those who want costs kept down, but they really are looking at insurance premiums — not the underlying reasons for the costs to be so high. In general, insurers take money from the insured, hold it for a bit while earning interest or investment returns, and then pay the providers. There is little incentive to hold down costs, since the more money charged by providers, the higher the premiums must be to cover this and the higher the amounts the insurer can invest. Where’s the incentive to look out for the little guy?

There are things that can be done to help address costs, making it all so much more solvable. Let me offer a few examples of the things that can be done without the benefit of the ACA.

Place health care providers on a budget

The people running health care services are bright and know how to manage. Give them a chance to manage, but within limits. If health care is given a budget, most managers will be able to maximize their services effectively. They can set priorities and stretch dollars. We should respect their abilities and let them go to work on services. How do you set a budget? One possible way is to have broadly representative regional entities work to set realistic budgets for the flow of total reimbursement dollars that recognize the unique characteristics of the region. A coalition of government, business, insurance, consumer and provider representatives could be established to run such a process of budgeting and their operating costs would be minimal.

Overhaul or eliminate unfunded service mandates

For example, the Emergency Medical Treatment and Labor Act (EMTALA) is a federal law that requires anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay. Since its enactment in 1986, it has remained an unfunded mandate. Similar mandates apply to obstetrics services. Hence, there is an open door to a hospital. The door can be closed or at least changed to reinforce the notion that people should be responsible for the financial consequences of their care. There are charity programs and governmentally subsidized programs like Medicaid for the poor. For the irresponsible who simply choose not to make it a priority to be covered, well … there should be consequences for those actions. Removing the mandates could go a long way to helping.

Examine community benefit

In Michigan, most of our health care institutions are nonprofit. This means they exchange the provision of community benefits in return for their tax-exempt status. Yet, who oversees if the value of their services really does offset their tax advantages? A true examination of the benefits they provide with similar benefits provided by for-profit institutions might be revealing, since the for-profit institutions often claim to provide the same unfunded benefits that their nonprofit colleagues do. Too long some of our nonprofits have said we simply should be grateful they exist, even though their charges for services don’t appear to be different from their for-profit colleagues. Many (not all) have become wealthy cash-cows with bloated bureaucratic overhead. Community benefit must be seriously examined on an impartial basis. Non-profit status should be denied to those who don’t provide a real difference.

Board representation

The boards of health care institutions should be truly representative of their communities. Too often they are composed of elites who may have problems understanding the needs of the populace. Some board members don’t even live in the community that is served. Most are males. There are few minorities. Younger citizens are rarely seen in the boardrooms. Administrators make it difficult for people to even know who is on the board, making it almost impossible for community members to express opinions. Since boards have the power to set rates for services, establish staff salaries, make capital decisions, guide the institution’s decisions about which services they can provide efficiently and set the moral tone for an institution, they should be held to a high standard of representation. They need to be able to stand up independently to those administrators who are less concerned about needless and costly duplication of services and facilities in a community, expansion of organizations without a clear benefit, and reducing charges instead of building huge financial reserves.

Government and charitable grants

These should be made available to fund cost-effective and innovative projects to improve the delivery of care and to reduce the costs. All too often, we are told of wonderful new tools to help make health care more cost-effective. Somehow, they end up costing us more. There needs to be an understanding that new projects will be supported, but only if they improve care and reduce costs. Let the health care folks work within this paradigm and they will respond. Using grants as incentive can more that recoup the costs of the grants.

These are just a few ways to fix the health care system.