Health care rad­i­cals

Our view: The pres­i­dent-elect’s picks for HHS and CMS por­tend a far greater trans­for­ma­tion of the health care sys­tem than Oba­macare

Baltimore Sun - - FROM PAGE ONE -

Back when Don­ald Trump was a rene­gade, pop­ulist in­sur­gent in the Repub­li­can pri­maries, he promised that he could save the na­tion’s so­cial safety net — pro­grams like Medi­care and Med­i­caid —“with­out cut­ting it to the bone.” But now he’s pres­i­dent-elect, and he’s as­sem­bling a dream team for GOP or­tho­doxy, threat­en­ing the very no­tion that ac­cess to health care is any­thing re­sem­bling a ba­sic right.

Mr. Trump’s choice to head the Department of Health and Hu­man Ser­vices, Rep. Tom Price of Ge­or­gia, is not just a lead­ing critic of the Af­ford­able Care Act. He also is some­where to the right of House Speaker Paul Ryan when it comes to gut­ting the fed­eral com­mit­ment to pro­vide health care for the el­derly and the poor. That se­lec­tion and Mr. Trump’s choice of health care con­sul­tant Seema Verna to run the Wood­lawn-based Cen­ters for Medi­care and Med­i­caid Ser­vices sug­gests a fu­ture in which costs and risks are in­creas­ingly passed on to the states and in­di­vid­u­als — a shift that will mean more unin­sured, more lives ru­ined by med­i­cal debts and no ap­pre­cia­ble ef­fort to trans­form the health care sys­tem to make it more af­ford­able and ef­fec­tive.

Dr. Price, an or­tho­pe­dic sur­geon, is a long­time ad­vo­cate of plans to make Med­i­caid a block grant in which the fed­eral gov­ern­ment pro­vides a fixed amount of money to each state, with the growth rate pegged at a level lower than med­i­cal cost in­fla­tion, while pro­vid­ing gov­er­nors with in­creased flex­i­bil­ity to cover fewer peo­ple and to of­fer them fewer ben­e­fits. And un­like many Repub­li­cans who­have of­fered pro­pos­als to re­place Oba­macare, Dr. Price’s plan would ditch the Med­i­caid ex­pan­sion the leg­is­la­tion pro­vided al­to­gether. That’s 13 mil­lion peo­ple who would lose care right off the bat.

Ms. Verna’s record sug­gests the pro­gram could change in other ways, too. She worked closely with of­fi­cials in In­di­ana (in­clud­ing Vice Pres­i­dent-elect Mike Pence) on that state’s ACA Med­i­caid ex­pan­sion. Un­like other states, In­di­ana got per­mis­sion from CMS to re­quire that ben­e­fi­cia­ries — even those with ex­tremely low in­comes — pay pre­mi­ums if they want full ben­e­fits. If they don’t, they can be frozen out of cov­er­age for up to six months. The pro­gram is a com­plex blend­ing of in­sur­ance choices, health sav­ings ac­counts and co-pays, and though it has led to in­creased cov­er­age, it has not made In­di­ana ap­pre­cia­bly health­ier — the state ranked 33rd-health­i­est in 2006, be­fore the ex­pan­sion, and 41st in 2015, ac­cord­ing to Amer­ica’s Health Rank­ings, a long-es­tab­lished an­nual re­port pro­duced by United Health Foun­da­tion and the Amer­i­can Pub­lic Health As­so­ci­a­tion.

As for Medi­care, the health in­sur­ance pro­gram for the el­derly, Dr. Price said after Mr. Trump’s elec­tion that he planned to fast-track pri­va­ti­za­tion, a long-held Repub­li­can idea in which se­niors would be pro­vided vouch­ers to buy what­ever in­sur­ance they choose. But those sub­si­dies would also grow more slowly than med­i­cal in­fla­tion, leav­ing se­niors to pick up more of the cost or to Rep. Tom Price, Pres­i­dent-elect Don­ald Trump’s pick to lead the Department of Health and Hu­man Ser­vices, wants to rad­i­cally trans­form U.S. health care. forgo ad­e­quate care. Mr. Ryan’s lat­est it­er­a­tion works a lot like the Oba­macare ex­changes — pri­vate in­sur­ers and the gov­ern­ment would of­fer plans from which se­niors could choose, and if they pick one that costs more than their sub­sidy, they pick up the tab. Dr. Price has also sup­ported rais­ing the el­i­gi­bil­ity age from 65 to 67.

All this would cut costs for the fed­eral gov­ern­ment — the Con­gres­sional Bud­get Of­fice es­ti­mated that Dr. Price’s Med­i­caid pro­posal would re­duce fed­eral spend­ing by $1 tril­lion over a decade, ef­fec­tively re­duc­ing the pro­gram’s bud­get by a third in the fi­nal year of that pe­riod. The sav­ings from the lat­est pri­va­ti­za­tion pro­gram for Medi­care aren’t clear, but Mr. Ryan has couched his pro­pos­als in terms of re­duc­ing the en­ti­tle­ment’s long-term costs — which is ironic in that Oba­macare ac­tu­ally ex­tended the sol­vency of the pro­gram by11 years.

But it wouldn’t nec­es­sar­ily cut costs for the health care sys­tem, and in fact, Dr. Price has been hos­tile to the fed­eral gov­ern­ment’s ef­forts to shift away from fee-for-ser­vice mod­els of pay­ment to­ward ones that fo­cus on qual­ity and out­comes — per­haps the most far-reach­ing of which is Mary­land’s Medi­care waiver. That ex­per­i­ment has held hos­pi­tal spend­ing growth in Mary­land to a cu­mu­la­tive 4.2 per­cent since Jan­uary of 2014, sav­ing Medi­care nearly $420 mil­lion. Mean­while, the hos­pi­tal read­mis­sion rate for Medi­care pa­tients here dur­ing that time dropped nearly 6 per­cent com­pared to the na­tional av­er­age, and the rate at which pa­tients ac­quire in­fec­tions in the hos­pi­tal has dropped by a third.

In all, Dr. Price and Ms. Verna of­fer the prospect of a health care sys­tem trans­formed far more rad­i­cally than Pres­i­dent Barack Obama ever at­tempted. That’s not what Mr. Trump cam­paigned on, but it may be what the Amer­i­can peo­ple are about to get.

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