The Quiet Attack on Obamacare

The Trump Administration can do plenty of damage to the Affordable Care Act even if Congress fails at repealing it.

By Nathan Pippenger

Tagged affordbudgetCongressHealth CareMedicaidMedicare

A month ago, Donald Trump told The Washington Post that he was nearly finished with an Obamacare replacement plan that would achieve “insurance for everybody” and leave people “beautifully covered.” He demurred on the details, saying he was waiting for the confirmation of Tom Price, his nominee for secretary of health and human services. For a time, Price’s nomination seemed to be in peril: As a member of Congress, he had not only written laws affecting the very health-care firms that were handsomely growing his stock portfolio; he also received a sweetheart discount on some shares in an Australian biotech firm—and lied about it during his confirmation hearings. Republicans were so appalled by this behavior that they voted unanimously to confirm him.

Now that Price’s conflicts of interest are ancient history and the country has an HHS secretary, Trump’s terrific, beautiful health plan is surely—like its counterpart from the GOP Congress—only days away. But in the meantime, even without a full repeal of the ACA or comprehensive new law in its place, Secretary Price can set to work remaking parts of the world that Obamacare helped to create.

One example, closely studied by health-care wonks, is the Center for Medicare and Medicaid Innovation (CMMI), established through Obamacare and funded with $10 billion for its first decade. The CMMI, intended to steer Medicare and Medicaid to lower payment costs and improved outcomes, has already awarded hundreds of millions of dollars in grants to states where pilot programs are being tested for complicated and expensive care situations. In Wisconsin, for instance, it has funded the creation of coordinated care teams for child patients with complex medical needs. Such children not only have expensive bills and high hospital readmission rates; their families are tasked with navigating a sometimes dizzying array of providers in multiple settings. A study of Wisconsin’s coordinated care program showed that costs and inpatient hospital days had fallen by more than half, while parents reported better satisfaction and health outcomes for their children. In the long run, the federal government can encourage wider adoption of the most successful pilot programs at the state level, simultaneously improving care for patients and reducing spending.

Secretary Price has been critical of the CMMI, and a 2015 Republican bill in the House proposed defunding all of its remaining budget—which would cut off the promising work the Center has done so far, prevent the broader implementation of improvements in the future, and increase health-care spending by tens of billions of dollars. Even short of that drastic defunding measure, the Center’s effectiveness can still be hampered if the secretary chooses to scale back ongoing projects or declines to exercise his authority to require health-care providers to participate in its experiments. Expect Price to do just that.

The high legislative drama surrounding ACA repeal has captured the bulk of attention in debates over health care. That’s understandable, but even if the GOP Congress proves unable to coordinate a repeal effort, it can still do long-term damage to the law. And this is not only a question about spending: In the long run, budgetary questions about costs become political debates about coverage. Failures to improve health-care outcomes and lower costs today become the excuse to cut care and slash programs tomorrow. The Congressional Budget Office recently projected that even with 20 million more Americans covered by the ACA, health spending is still more than $600 billion below what it would have been in a world without Obamacare. Part of that policy success is due, as a recent report from the Center on Budget and Policy Priorities puts it, to “structural changes” in the health-care system created by the law’s “incentives to improve efficiency and quality.” CMMI has been part of those changes, and the quiet undermining of its mission will harm health care for Americans—both today and in the long run—whether repeal proceeds or not.

Read more about affordbudgetCongressHealth CareMedicaidMedicare

Nathan Pippenger is a contributing editor at Democracy. Follow him on Twitter at @NathanPip.

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