Now that King v. Burwell was decided as it should also have been decided, with rejection and Muntzian laughter, what’s next for healthcare reform.
There are two sets of legal challenges still out there that could have significant impact on PPACA. The first is a challenge against the funding of the Cost Sharing Reduction (CSR) subsidies. The law authorized the money to be paid, but it was fuzzy if these funds were automatic funding (like Social Security) or discretionary funding. The Obama administration has been paying these funds as if they were automatically funded. To me, this sounds like a political dispute that the courts won’t want to touch.
The second set of legal challenges are the far more common set of challenges. “What does that actually mean…” For instance the law requires all insurance plans to offer reasonable access to all needed providers. Is a single PCP with an open panel 22 miles away from what someone lives, reasonable access? Is the CMS guidance sufficient to fulfill the law? I have no idea, let’s go to court.
Forty percent of the states still have not expanded Medicaid.
From a system perspective, Obamacare is part of the policy/economic mix that broke the second derivative of cost increases. This is a massive win at the federal fiscal level. However, part of the win is probably the proliferation of high deductible health plans which make people cut back from needed care. And so far, our pricing per unit of service is still way too high. As commennter Keith G notes:
Now that Obamacare has what seems to be an extended shelf life, we can turn our attention to the next health care battle. Life-saving pharmaceuticals are still priced too god damn high for Americans. This needs to stop. While I can afford the Obama care premiums every month, what I can not afford are the $1000 per prescription (x3 drugs) cost of my monthly stay alive drug supply.
Luckily I have AIDS….
We need to get higher actuarial value coverage to more people and bring down the costs per unit of service at the same time. Some of that will happen with narrow networks, some of it is happening with Accountable Care Organizations, some of that is happening to market pressures. We need to get the Federal Trade Commission more involved with a preliminary stance that most consolidation deals are a net negative to consumers.
In the Medicaid expansion states, we’re at about 80% of the probable maximum expansion. We need to get to 100% of probable maximum expansion and hopefully do a Michigan and blow by the coverage expansion goal. In the non-Expansion states, we’re probably at 40% maximum coverage.
Section 1332/State Innovation/Wyden Waivers should be the next big set of discussions. These waivers allow states to meet Obamacare coverage and affordability goals through state customized plans with very few constraints. The Feds will pick up the cost of state experimentation. In a rational political universe, this should be extraordinarily attractive to conservative states as they get to try conservative healthcare solutions (besides dying quickly of course) with federal money. In reality, most of the action on 1332 waivers is coming from Blue states.
Drinking their milkshakes
Peter Suderman (husband of McMegan, and general libeterian dude-bro) had a good point about conservative healthcare policy in a recent Politico article:
Republicans have already lost, because when it comes to larger health policy goals, the party effectively doesn’t have any beyond the repeal of the Obamacare. In the long term, Republicans can’t win this fight because they don’t know what winning means….Obamacare, in other words, was ClintonCare’s second act—the culmination of more than 15 years of work and consensus building. To put it another way: Republicans never started working on health policy; Democrats never stopped.
Policy victories will go to the Democrats on health policy for a very simple reason; they are the only ones with any political backing who are engaged in examining pro-active policies. Republicans can veto and say no, but they can’t advance active changes because their policy translation apparatus from a few wonks to actually writing legislation is broken.