Hospital executives' 12 most pressing post-election questions, answered

With a Republican sweep of the White House and Congress, last week's election could lead to major health policy changes, according to The Advisory Board.

In a perspective piece, Chas Roades, chief research officer at The Advisory Board, outlined the most common questions he has received from those in the healthcare industry following the election. Below are the top 12 questions Mr. Roades has received.  

1. Will the ACA be repealed? It is likely some form of ACA repeal will be a high priority for President-elect Donald Trump's administration, according to Mr. Roades. In a policy brief released last week, Mr. Trump said the repeal of the health reform law will be paired with a replacement effort that includes expanded health savings accounts, re-established high-risk insurance pools, flexibility for states in administering Medicaid and a revamped approach to Medicare. In an interview with the Wall Street Journal, Mr. Trump said he would consider leaving certain parts of the ACA in place, such as the provisions that prohibit insurers from denying coverage due to a patient's preexisting conditions and allow parents to keep children on their health insurance policies for additional years.

2. How will provider rates of uncompensated care be affected if Medicaid expansion is repealed? Republicans may seek to repeal Medicaid expansion, which was enacted under the ACA, according to Mr. Roades. This would lead to an increase in uncompensated care and bad debt, as it would cause reduction in the total number of people covered by Medicaid. "Organizations should prepare for the possibility that the Medicaid expansion is undone, bad debt rises and [Medicaid Disproportionate Share Hospital] payment cuts still eventually kick in," said Mr. Roades. 

3. How would Medicaid reform affect healthcare organizations' finances? Mr. Trump has proposed Medicaid reforms that would limit growth of federal funding for Medicaid and give states greater flexibility in administering the program. These reforms may cause some states to limit Medicaid eligibility, payment rates or benefits. "For providers, this would portend lower revenue and a need to double down on efforts to reduce costs," said Mr. Roades.

4. What will happen to the ACA health insurance exchanges? The future of the ACA exchanges is uncertain, according to Mr. Roades. He notes that Republicans may repeal the exchanges and implement a transition plan that phases out the subsidies.

5. Will the ACA's cuts to long-term Medicare spending be repealed? Medicare spending cuts under the ACA are likely to remain in place. Mr. Roades highlighted that previous legislation approved by the House to repeal the ACA left the long-term Medicare spending cuts intact. This means healthcare provider organizations would have to endure the Medicare price cuts without the upside of coverage expansion, according to Mr. Roades.

6. What is the future of payment reform? There's a lot of uncertainty surrounding existing risk-based payment and pay-for-performance models. If providers and key stakeholders voice a preference for value-based care models over deeper fee-for-service rate cuts, the Trump administration and new Congress may support the payment models.

7. What will happen to bundled payment programs? Although some Republicans have taken issue with CMS' Comprehensive Care for Joint Replacement model and the proposed Episode-Based Payment Model, it is unlikely bundled payment programs will come to an end, as they have general support from both parties, according to Mr. Roades.

8. Will ACO programs continue? A full repeal of the ACA would mean the Medicare Shared Savings Program would be eliminated. However, Mr. Roades noted Republicans haven't proposed a replacement for alternative payment models such as MSSP, and there has been no indication the alternative payment models would be included in more specific repeal efforts.    

9. Will the Centers for Medicare and Medicaid Innovation be eliminated? Although it's unclear if CMMI is on the chopping block, Mr. Roades noted previous House bills to repeal the ACA eliminated CMMI's funding and authority.

10. How will the election affect MACRA? Although the Medicare Access and CHIP Reauthorization Act has strong bipartisan support, action to cut back alternative payment models, such as repealing the ACA or defunding CMMI, would undermine MACRA's effectiveness, according to Mr. Roades.

11. What does the future hold for Medicare Advantage? "While it is not likely that MA…will fully supplant traditional Medicare in the immediate future, providers would be wise to craft strategies that address both the MA and traditional Medicare segments in complementary, scalable ways," said Mr. Roades.

12. Will Medicare move toward a premium-support model? House Speaker Paul Ryan's plan for Medicare includes transitioning the program to a defined-contribution or "premium-support" model from a traditional entitlement model. However, Mr. Roades noted it is not clear whether President-elect Trump supports the plan.

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