A Policy Prescription for 2018

The controversy over health care reform often boils down to two issues: coverage and cost. The Affordable Care Act (ACA) made significant impact on the coverage issue, dropping the uninsured rate below 10% for the first time in the recorded history of the United States, covering 20+ million Americans in the 8 years since it was passed, and putting the United States on a reasonable path toward universal coverage.

Despite its name, however, the ACA has not made health care “affordable” for the vast majority of Americans. While the individual marketplace has offered reasonable, comprehensive coverage to nearly 10 million customers in the individual market, premiums continue to climb, deductibles continue to rise, and the opacity of health care pricing persists.

While liberals often focus on coverage and conservatives tend to care about costs, what can health reform advocates on either side of the political divide accomplish in 2018, tempered by the fact that the enemies of Obamacare control the White House and the Congress? In this – my annual policy prescription – I detail a few possible ways advocates can act to improve on coverage numbers while also suggesting a means to reduce the cost of care in the United States. It’s simple, really. Let’s ask voters and the states to bring coverage options to more Americans while asking the federal government to make meaningful changes designed to bring down the cost of health care.

The next step in coverage expansion should be the continued pursuit of Medicaid expansion in the remaining non-expansion states. Closing the Medicaid Gap in states that have yet to do so has the potential to cover over 2.3 million Americans. Last November, voters passed a ballot initiative in Maine bypassing an unwilling state legislature. Advocates on the ground in Idaho, Utah, and Nebraska are currently considering identical strategies. If successful in all three, 168,000 Americans could gain coverage. For Senators Deb Fisher (Nebraska) and Bill Nelson (Florida) who will all be attempting to get re-elected this fall, their constituents should make minding the Medicaid Gap into a campaign issue. In Utah, where Senator Orrin Hatch plans to retire, candidates for this wide-open senate seat should consider that two-thirds of Utahns want Medicaid expansion.

Advocates in other states – especially Florida, Georgia, North Carolina, Tennessee, Texas, and Virginia – should inquire if enough interest exists in expanding Medicaid by ballot initiative there. Odds are it does, as opinion polling shows that Americans view the Medicaid program favorably (71%) and also think that it works well in their own state (64%) even among people residing in non-expansion states.

The other option advocates could pursue would be to open up their state Medicaid program as a “public option.” Nevada recently passed this type of plan through its legislature, although it was vetoed by the governor. A broader public option proposed by Hawaii Senator Brian Schatz and New Mexico Congressman Ben Ray Lujan would allow a Medicaid Public Option in every state. Polling shows favorable views of a public buy-in option (such as a Medicare buy-in) across the political spectrum. Because it remains unlikely that the current Congress and White House will act on these bills, advocates may choose instead to push for a state-by-state Medicaid buy-in wherever it is politically feasible.

Now, let’s discuss health care costs. For the rapid rise of health care costs to abate, two things need to occur. At the federal level, it is past time that the Medicare Prescription Drug Benefit (Part D) be allowed to create a formulary, exclude drugs that are expensive yet have cheaper alternatives, and to negotiate drug prices with the pharmaceutical industry. Albeit almost impossible with a president who reneged on his campaign promise and with a Secretary of Health and Human Services nominee who previously was on the payroll for Eli Lilly, there are bills in Congress that would allow Medicare to accomplish that task. Those bills – HR 4138 (sponsored by Elijah Cummings of Maryland) and S 2011 (sponsored by Bernie Sanders of Vermont) could save taxpayers at least $230 billion over10 years.

Additionally, advocates should encourage the adoption of all-payer claims databases. While states could get a large swathe of insurers to contribute information, due to a recent Supreme Court ruling, many self-funded (i.e. ERISA) health plans would be excluded. If the federal government will not waive that pre-emption, advocates should call on Congress to facilitate a federal all-payer claims database which would incorporate private insurance and public health program payments. The market faithful must agree that in order to make a health care market work, we require price transparency. The first step is knowing what prices are actually being paid for health care services across the country. The proprietary nature of health care transactions keeps health care costs opaque and permits excessive medical price inflation.

If advocates can rally behind various reforms in 2018 – grassroots efforts to expand Medicaid, an option for Americans to buy into their state Medicaid program, price negotiation and formulary creation for Medicare Part D, and robust support for all-payer claims databases across the country – we can accomplish the dual goals of expanding coverage and cutting health care costs.

*This post has been updated to reflect that Senator Orrin Hatch is expected to retire, leaving an open race in Utah for 2018.