Election Day is here, and several issues hang in the balance. The pandemic has been at the forefront of everyone’s minds throughout the debates, but there are longer-lasting policies at play that could impact the future of our healthcare. Both candidates are all about reducing the unsustainable cost of healthcare in this country, but getting there looks very different. Much will depend on who wins what election, though most predictions believe Democrats will retain the House of Representatives. If they don’t win the Senate and presidency, there will probably be more of the same kind of stalemate that existed during the Trump and Obama years. Biden’s plan would embrace something close to a universal payer, with a return of the individual mandate; it would allow undocumented immigrants access to a plan as well. The plan would also give Americans the ability to buy into a Medicare-like health insurance option and expand coverage to low-income earners.
While there are both humanitarian and fiscal advantages to giving more people insurance, there are unintended consequences. The Centers for Medicare and Medicaid Services has reduced reimbursement rates to control costs. While more insured individuals would create more potential patients, the reimbursement rates will be lower than those paid by commercial insurance. And because many commercial insurance payers use Medicare reimbursement rates as their benchmark, there may be revenue decreases for physicians and providers, thus destabilizing their businesses’ cost structure. “The approach is not going to work because you’re squeezing the physicians so much that they’re not going to be able to deliver the excellence and care,” says Dhruv Chopra, CEO of Collaborative Imaging. “They’re going to have to make a choice as to whether they invest in their practices and get the latest technology or whether they use what they have and drag that out longer, which was not a choice historically. Historically, you could do both.” Trump promised to remove the Affordable Care Act on “day one,” which didn’t happen. Still, the individual mandate was removed, leading to a lawsuit that will soon be heard by the Supreme Court to decide whether the act and the protections that go along with it are constitutional without the individual mandate. His plan would also allow individuals to deduct their premiums from their tax returns, provide block grants to states to administer their Medicaid programs, increase price transparency, and allow insurers to sell across state lines. Chopra worries that a continuation of Trump’s policies will result in more high deductible insurance plans. Patients are footing the bill for thousands of dollars a year before their insurance kicks in. Thus, many patients are negotiating with hospitals and providers for a cash payment option, rarely even using the insurance they pay premiums into every month. “The insurance companies are making so much money and profit because health insurance is now catastrophic insurance,” he says. “You only use it when you’re going to get admitted to the hospital, or you’re going to have surgery or something to that extent. Outside of that, patients just do a cash pay.” Also, there will still be millions without insurance at all, creating additional challenges. “Not only is reimbursement going to go down for the providers, but the cost to collect that money is going to go up,” Dhruv says. But the two plans have several similarities as well. Both candidates want to ban or limit surprise medical billing and put downward pressure on pharmaceutical prices through importing drugs or allowing Medicare to negotiate. Both candidates want to give the patients more control of their care and access to their medical records, which they can share with other providers. “In five to seven years the electronic medical record as currently configured will disappear, replaced by the cloud,” says John McCracken, clinical professor of healthcare management at the University of Texas at Dallas Jindal School of Management and adjunct professor of family and community medicine at UT Southwestern Medical Center.
“Let the doctors be doctors that just take care of their patients.Dhruv Chopra, CEO, Collaborative Imaging
There will also be progress toward shared risk arrangements and value-based reimbursement through accountable care organizations—ACOs, which incentivize positive outcomes that result from preventive care—and other structures in an attempt to bring costs down. Both candidates also support the disruption of the current delivery model by non-traditional players. Chopra thinks healthcare savings can be found from reducing administrative overhead rather than reducing reimbursement rates and continuing the sale of high deductible plans. Compliance, reporting, billing rates, and malpractice insurance all create additional burdens on physicians who want to care of patients. These requirements take money from what providers could use to treat patients. “Let the doctors be doctors who just take care of their patients,” he says. “Let them practice medicine, and don’t bombard them with all these additional metrics and reporting.” Looking ahead, McCracken wonders if pricing control will come from market forces like increased transparency or increased government control. He wonders if states will be allowed to innovate with solutions or if there will be more federal control. “I suspect the answers to both lie in the ultimate resolution of the approaching national discord and reinvention as the nation rethinks and reshapes its relationship with the Federal government,” he says. “The big, long-run issues of healthcare pricing and control will require more than one election cycle to resolve.”
“The big, long-run issues of healthcare pricing and control will require more than one election cycle to resolve.John McCracken, clinical professor of healthcare management at the university of Texas at Dallas Jindal School of Management