Northwell CEO Michael Dowling: What I'd like to see when Congress resumes the healthcare debate

The ACA has been one of the most hotly debated legislative issues in the history of this country. For seven years, Republican lawmakers have been calling for a repeal of the ACA, and after months of congressional drama, it appears their efforts have stalled for the time being. This is not a loss or a win for either political party, but instead a moment for careful reflection.

It is not simply policies that need fixing, but the political mechanisms that are supposed to turn theory into action. Though the democratic process is historically slow, the gears of this legislative machine have seemingly ground to a halt. This is a dangerous precedent with serious implications, including an increasing loss of trust in the institutions of government.

It seems as though compromise is a dirty word to many lawmakers in Washington. If we have learned anything from Congress' recent healthcare efforts, it is that meaningful legislation cannot be crafted by one party alone. Hopefully, the failed attempts to repeal the ACA will prove to members of Congress that they need to reach across the aisle to come up with solutions that provide robust, affordable coverage to Americans. Partisanship, excessive ideological fervor and negativity do not work. It is also important to appreciate that while improvements need to be made in our healthcare system, there is much that works well. Our successes have greatly surpassed any failures.

Plans offered up by House and Senate leadership over the past several months were often projected to hurt more people than they helped. These options are simply unacceptable. People need insurance and access, and any policy that leaves more people without coverage is not deserving of consideration by Congress. Nevertheless, steps must be taken to address fundamental problems with the ACA.

What needs to be done

Cost-sharing reduction (CSR) subsidies are essential for stabilizing individual insurance markets, and though funding for CSRs has been secured through 2017, lawmakers need to ensure these payments continue in 2018. Congress also needs to strengthen the individual mandate, which imposes penalties that many Americans elect to pay instead of buying insurance plans. The purpose of this mandate is to encourage healthy people to participate in the market so the health exchanges do not simply turn into risk pools for the sick.

Medicaid expansion under the ACA enabled millions more Americans to gain insurance coverage and is an essential way for lower-income communities to access the care they need. States should be given more flexible control over their Medicaid programs to encourage innovation that results in policies tailored to the needs of their residents. These changes should be made within the guardrails of Medicaid's fundamental principles while leaving room for creative changes by state policymakers.

While Medicaid-reliant providers are currently under water, they will drown completely if Medicaid reimbursement rates are lowered further. Providers — not politicians — are the ones on the front lines of healthcare in this country, yet we are often painted as villains who have profited from the ACA. Rarely is it reported that providers have seen their Medicare reimbursements cut by tens of billions of dollars since the ACA took effect. If politicians want to know what to do about healthcare, it would be wise to spend some more time with providers to better understand the realities of what is happening on the ground.

Healthcare delivery in this country can be improved through a renovation, not a demolition, of current legislation. Our lawmakers simply need to stop playing politics and work with each other, while also engaging with healthcare leaders who can offer valuable insight and practical solutions.

The role of government

One of the central questions at the heart of the healthcare debate has been what the government's role should be in healthcare. Since ACA repeal efforts stalled, there have even been calls from the left for a single-payer system. While this solution may sound attractive in theory, full government control of health insurance would be disastrous from both a financial and delivery standpoint. 

Most single-payer systems around the world have evolved into a two-tier health delivery system in which those who can afford to purchase private insurance can gain quicker access to care, while the "have nots" face long delays. Single-payer systems not only limit the ability of citizens to access care, they also stifle creativity and entrepreneurial pursuit within our industry. Considering the realities and complexities of the American healthcare system, any proposal advocating a single-payer approach should be taken off the table.

Congress' inability to develop effective healthcare legislation is frustrating, but should not be taken as a sign to saddle our industry with further micro regulations.

Government has an important role to regulate and provide guidelines for how the industry should operate. Roughly 60 percent of most providers' revenue comes from Medicare or Medicaid, making the government the largest payer in the nation. The trick now is for the government to get out of its own way and stop functioning under the assumption that providers are bad actors who need incessant intervention and oversight. Frankly, it's insulting and underestimates the hard work that everyone on the provider side of the industry gives to ensure patients receive the highest quality care possible.

The government is an inherently risk-averse entity, but the only way to innovate and create solutions to our most pressing healthcare problems is for industry leaders to continue to take steps in a bold, new direction. While the relationship between payers and providers can be acrimonious, we have found ourselves on the same side of the most-recent ACA repeal-and-replace debate, and more and more constructive collaborations have occurred in recent years.

Developing workable healthcare policies that benefit patients, providers and payers will require new, non-traditional partnerships that align providers' clinical performance and outcomes with financial incentives. But it can't be the insurance companies alone that benefit from efficiencies and cost savings made possible by providers. There must be value for both payers and providers — as well as consumers and employers.

Competition encourages all parties to work harder and, ultimately, better. Elected officials and policymakers need to build legitimacy and reduce their unbelievable addiction to partisanship. Most importantly, over the course of this continuing debate, everyone should remember to think as consumers and patients, and consider how they would like to be treated if they were in need of care. All should aspire to the kind of access and care that members of Congress enjoy.

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