Republicans have begun the labyrinthian process of repealing and replacing ObamaCare. It will undoubtedly end up taking longer than President-elect Donald Trump believes, and the process will be far messier, but in the end it will happen. The question, therefore, is what will health care look like post-ObamaCare?
For the last two days, we have looked at what ObamaCare repeal and a Republican replacement will mean for consumers and patients. Any Republican plan is almost certain to expand health-savings accounts (HSAs) and allow you to purchase insurance across state lines.
There will be an expansion of association health plans, and it will be easier to join a group insurance plan. You will be able to buy lower cost, less comprehensive insurance that better fits your individual needs, rather than a one-size-fits-all plan designed in Washington.
All this means that consumers will have more choices and be able to find cheaper insurance. The expansion of HSAs means that it will be easier to keep your insurance if you change or lose your job.
Not everyone will be a winner, however. Subsidies will be reduced meaning some lower-income workers may have to pay more or buy less-comprehensive insurance. And the mechanism for dealing with pre-existing conditions remains unsettled. Some plans would continue ObamaCare protections in a more limited form, but those proposals could further destabilize the insurance market. Other plans would provide health care directly to the small number of truly uninsurable Americans, most likely through a reformed Medicaid program.
But what would the repeal of ObamaCare mean for doctors and the medical profession? First, they will avoid the dramatic pay cuts to come. Part of ObamaCare was paid for by increasing the debt and imposing more than $1 trillion in new taxes on Americans. But ObamaCare was also funded through significant reductions in reimbursements to doctors and hospitals under Medicare. Repealing ObamaCare means that the Independent Payment Advisory Board (IPAB), which was to have started imposing those cuts next year, would be out of business.
Hospitals would have been hit hard if those cuts occurred. Predictions by Medicare's own actuaries warned that as many as 15 percent of hospitals and other health-care facilities could be forced to close. Many of those facilities may now survive.
At the same time, private insurance was also responding to ObamaCare's impact by squeezing physician payments, as well as by reducing the number of doctors and hospitals covered through their networks. Some insurers were dropping many of the best — and therefore most costly — doctors and hospitals altogether. With consumers having more choices and more control over their health care spending under Republican proposals, they may well demand more provider options as well.
Still, one shouldn't get too excited. US health-care spending, the world's highest, is not sustainable over the long run. Medicare is roughly $58 trillion in the red going forward. Changes, probably including reimbursement cuts, are inevitable. And if consumers are spending more of their own money for health care, they are likely to demand lower costs (and higher quality) the way they do for other goods and services. Not every physician will appreciate a more involved — and questioning — customer.
There are also some ObamaCare-related changes that are likely to remain. ObamaCare sped up the process of consolidation in the health care industry. The number of hospital mergers, for instance, roughly doubled since ObamaCare took affect. That trend will probably continue. And, the day of the small independent medical practice is over. Physicians will increasingly work directly for hospitals or other organizations. So-called concierge medicine will expand. The days of Marcus Welby, M.D. are gone forever.
Similarly, the movement away from fee-for-service medicine and into some form of managed care will continue. Payments will become increasingly based on outcomes rather than inputs. The payment changes and burdensome reporting requirements under MACRA (the Medicare and CHIP Reauthorization Act) will still happen.
Nurse practitioners, physician assistants and other sallied professionals will continue to assume a wide array of duties previously undertaken only by a physician. And there will be a growing role for health-advisory services to help consumers negotiate a changing market place.
As we have seen over the last three days, repealing and replacing the Affordable Care Act will not mean returning to the pre-ObamaCare status quo. In fact, most Americans will find themselves better off, while a solution will have to be found to help those few Americans who need it. But here is a simple fact: ObamaCare's days are numbered. Change is coming. It's time for Americans — consumers, patients, taxpayers and health-care providers — to get ready for those changes.