Tomato Queen asked a good question in comments yesterday on my post about a proposed national all payer claims database:
Why is this being done now? Is it a shiny object to distract? I see it’s bi-partisan, and am deeply suspicious, esp as it sounds like two good ideas, one for the customers, the other for the kids in the back room, are appearing in the same bill. How the hell did that happen?
I think we need to look at the political incentives in broad strokes after we look at recent health policy history.
Post-2009 Medicaid and the individual market coverage expansions are highly polarized health policy pursuits on the Hill. The parties don’t agree on fundamental values therefore any movement in any direction is a slog.
However, Congress has shown that it is more than willing to work on a bipartisan and somewhat technocratic basis on non-Medicaid and non-individual market coverage health policy options on a repeated basis since March 23, 2010. The big bills that have gone through have been PDUFA 5 which changed how the Food and Drug Administration (FDA) considers evidence and approves drugs, MACRA which re-authorized CHIP and permanantly got rid of the Sustainable Growth Rate formula that was an ongoing and recurring farce. 21st Century Cures Act again changed and quicken the FDA approval process for new drugs.
Congress can act on health policy and they have acted on health policy. Yesterday, Dylan Scott at Vox looked at some of the major players involved in the bipartisan surprise billing talks and dueling bill drafts:
The Alexander-Murray proposal joins several others that have already been introduced: a recently released House bill from Reps. Frank Pallone (D-NJ) and Greg Walden (R-OR); another Senate bill by Sens. Bill Cassidy (R-LA) and Maggie Hassan (D-NH) released last week; yet another House proposal from Rep. Raul Ruiz (D-CA) and Phil Roe (R-TN) that came out on Thursday. Rep. Lloyd Doggett (D-TX) also introduced a bill back in January. Congress really is serious about doing something on surprise bills.
The notable thing about all of these bills is that the lead sponsors (or at least their senior policy staff) can easily and readily count to eleven with their shoes on when it comes to health policy. These bills are being introduced and championed by people with significant knowledge, interest and most importantly, control of several critical legislative chokepoints. If there is an agreement among these stakeholders, there is a clear pathway through the Hill.
So that brings us back to the basic question of WHY?
The surprise billing mainly falls on people who are not on government health programs. Medicaid recipients have no money for the surprise billers to chase, and Medicare has strong rules to protect and limit the size of surprise shocks. Surprise billing is a problem for people who get their insurance primarily through employers. Surprise billing is also an individual market problem but it is a much smaller problem.
If surprise billing is primarily a problem for people with insurance through their employers, it is primarily a problem for people who have moderate or higher income and are over the age of thirty. Another way of characterizing a population with moderate or higher income and over the age of thirty is “likely voters”.
All of the bills under discussion hold the patient harmless for any cost sharing above normal in-network rates. This makes the insurance as experienced by a patient far more valuable and far less confusing/anxiety inducing. Politicians of any party like to make likely voters happy if they can plausibly claim credit for the reason of happiness. Politicians also like to make their likely voters happy if there aren’t too many hard trade-offs and hard fought pay-fors.
This is the simple and somewhat crass explanation.
The slightly more complex version is that the health finance markets are kludgy at best. Eliminating or at least reducing a segment of the market which is currently an informational and contractual blackhole of doom helps the markets perform slightly better. There is no viable minimum winning coalition that wants to nationalize all US healthcare facilities so making the markets work slightly better is a common area of agreement among both parties (the question is usually what market and what is “better”? and whose rentier interests are gouged).
The All Payer Claim Database (APCD) segment falls into the same bucket. The healthcare markets are a massive informational black hole. An APCD with complete information could at least help us see the event horizon better and plan around it. If there is better negotiations due to better information that leads to lower price levels, it solves or at least contributes to solving a major federal policy problem without much risk or effort on the part of the current and future Congresses.