Advocacy Corner

Carter L. Alleman, J.D.

The Known Unknowns of Health Care

Just like all of you, I too must complete continuing education courses for my license, and trust me the courses are not even remotely as interesting as the ones I have seen at the ACA. My presenters believe PowerPoints should just be in black and white, covered with text, but alas that is not where this end of the year piece is headed. During the ethics course, I picked up the summation of the last couple of years of healthcare policy, the known unknowns.

“Reports that say that something hasn't happened are always interesting to me, because as we know, there are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns – the ones we don't know we don't know.” -  former Secretary of Defense Ronald Rumsfeld

There are many known unknowns that exist in the new make-up of Congress and the Trump Administration.

The Affordable Care Act (ACA), including its various quality, funding and payment provisions, and related regulations and regulatory waivers – will be:

  • Modified by legislation?
  • Modified by rulemaking?
  • Modified by Executive Order?

A Democrat lead House is showing signs of pushing through a package to strengthen the ACA. Will this package survive a Republican Senate? Recently, Senator Manchin (D-WV) met with President Trump and brought up the bipartisan agreement from the end of 2017 to strengthen the ACA, will the President back it? The Trump Administration released rules for short term basic health insurance plans while removing the individual mandate; will health exchanges continue to grow in 2019?HHS reduced the budget for ACA enrollment for 2018, and the data is showing a slower enrollment period. Will there be a large surge at the end as in previous years? No one knows.

Medicare Access and CHIP Reauthorization Act (MACRA) – will be:

  • Modified through legislation?
  • Modified through rulemaking?

I will bet the house that MACRA will not be modified by Executive Order, the other choices could very well occur. Congress is very hesitant to make changes to MACRA as it is their one large bipartisan law passed in the last couple of years. MedPAC released a report calling for the repeal of MIPS. CMS is working to continue flexibility, however it still is not releasing its attribution models and cost models for the 2020 payment year. CMS is slow to approve any addition Advanced Alternative Payment Models for specialties. Talk to any policy person, the same reply will be, yes we know that MACRA needs modified but we do not know when or how.

With the great many known unknowns, advocacy is a key to assuring that the ACOS members have a seat at the table and their needs are heard.