Republicans and Democrats must give a little to get a little

After his dramatic vote against the Republican healthcare bill, Senator McCain (R-Ariz.) encouraged his colleagues “…to trust each other, stop the political gamesmanship, and put the healthcare needs of the American people first.” 

Given the years of partisan rancor, how can our elected leaders move forward in a bipartisan fashion to improve the delivery of healthcare for the American people? 

Quoting McCain again, each side “must give a little to get a little.”

{mosads}Republicans must acknowledge that the Affordable Care Act (ACA), including its expansion of Medicaid, is law. It enjoys the support of a majority of Americans. It secures important consumer protections and establishes a framework of coverage for millions of Americans. Republicans must stop with the partisan rhetoric of repeal and commit to working with the Democrats to improve the law.

Democrats must acknowledge that the ACA became law without Republican support and that now is not the time to further polarize our politics by pressing for a single-payer health plan. Instead, Democrats should be open to Republican ideas about how flaws in the ACA might be addressed.

A bipartisan set of solutions to the flaws in the ACA is neither novel nor controversial. Such solutions should stabilize the individual insurance markets, help lower costs for Americans ineligible for federal subsidies, and allow for localized experimentation to inform future improvements to the ACA.

Of particular note, the “Problem Solvers Caucus,” a bipartisan group of over 40 members of the House of Representatives, has advanced an array of fixes for the ACA that can earn support from Republicans and Democrats alike. The proposals outlined below are largely consistent with and expand upon these recommendations.

Stabilizing individual markets across the nation is straightforward to accomplish. The Trump administration must continue cost-sharing reduction payments, enforce the individual mandate, maintain an extended enrollment period, and advertise to encourage young and healthy Americans to purchase coverage through the exchanges. 

Each of these steps is necessary to sustain the individual insurance markets and can be implemented without any further acts of Congress. Presidential threats to “let ObamaCare implode” only create uncertainty and destabilize the individual markets. 

Moderating costs in the exchanges is an elusive but not unattainable goal. Congress should amend the ACA to extend its reinsurance and risk corridor programs, both of which expired at the end of 2016. The state of Alaska, which has a Republican governor and legislature, obtained waiver authority to implement the Alaska Reinsurance Program to reduce its exchange premiums by 20 percent beginning in 2018. Reinsurance lessens the exposure of insurance companies to high cost patients, and risk corridors minimize insurance losses in what are still immature markets. Both programs will reduce costs to consumers.

To provide financial assistance to those Americans who exceed the income threshold to earn subsidies towards the purchase of insurance on the exchanges, Congress should adopt the idea advanced by Senate Republicans in the “Better Care Reconciliation Act” to raise the threshold on Health Savings Account contributions to equal ACA deductible and out-of-pocket spending limits while expanding HSA-eligible expenses to include health insurance premium payments. 

Last, Congress should encourage creative approaches to expanding coverage and lowering healthcare costs. Congress could amend the ACA to permit states to adopt the approach taken by Arkansas as an alternative to Medicaid expansion. Arkansas, which is a a deep red state negotiated a waiver to create a private option that allows Medicaid funds to be used to purchase private insurance on its exchange.

The private option could entice the Republican governors of the 19 non-expansion states to accept federal Medicaid funding and extend coverage to up to 2.5 million more Americans. Congress could also amend the ACA to permit individuals to purchase Medicaid plans offered through the exchanges.

This idea, advanced by Democrats in the Nevada legislature but vetoed by Nevada’s Republican Governor, would have created a Medicaid buy-in, an approach that may help the 3 million Americans who have zero or only one private insurer offering plans on their exchanges.

Finally, Congress could amend the ACA to auto-enroll uninsured Americans into a default, high-deductible catastrophic health plan, similar to the plans that were permitted temporarily by the ACA and included in the “Patient Freedom Act” introduced by Republican Senators Collins and Cassidy.  

Beyond these proposals, Congress should continue its bipartisan endorsement of the transition from volume to value based payments in healthcare. The cost of healthcare in the United States will be lowered only when provider reimbursement is aligned fully with the delivery of healthcare that is population-centered, coordinated, high quality, effective, waste-free, and sensitive to the social needs of our most vulnerable patients. 

In a letter to his Secretary of War, Timothy Pickering, President George Washington wrote, “But such, for wise purposes, it is presumed, is the turbulence of human passions in party disputes, when victory more than truth is the palm contended for.” Now is the time for our elected officials to set aside their quest for absolute victory. Let’s seize this moment to chart a bipartisan path forward, where we give a little to get a little. Returning one last time to Senator McCain, “We can do this.”

Dr. Kenneth L. Davis is President and CEO of Mount Sinai Health System, one of the nation’s largest integrated health systems. As a neurobiologist, Dr. Davis’s pioneering research led the FDA to approve four of the first five drugs for the treatment of Alzheimer’s disease. Arthur A. Gianelli is President of Mount Sinai St. Luke’s. He served since 2006 as President and Chief Executive Officer of NuHealth (the Nassau Health Care Corporation). He also served as the organization’s Executive Vice President and Chief Operating Officer.

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