As you have no doubt heard, the AHCA failed to get a floor vote because there weren’t enough representatives who were willing to vote for it. While the immediate threat of the ACA disappearing is over for the moment, this policy failure leaves a large number of issues and questions in its wake.
Current State of the Republican Health Policy Initiative
I suspect that the national republican party didn’t anticipate winning the presidency. As Paul Ryan has pointed out, they had been the opposition for 10 years in the House, and their policy efforts had been to score political points not to have implementable bills. In fact, practical bills would have undermined their opposition strategy. The AHCA effort has publically surfaced long-standing internal differences between moderate, establishment, and conservative factions in the Republican Party.
It is clear that no macro-policy change will occur in healthcare in the short term because it is very difficult to imagine a healthcare consensus among these factions. If the 30 members of the Freedom Caucus can prevent internal consensus on major RNC policy initiatives (at least around social justice issues), there aren’t going to be any in the near term.
The Status of the ACA
The ACA won’t be replaced anytime soon. But there are important problems with the way the ACA is evolving as a market mechanism for managing health insurance. In ordinary reality, these issues would be dealt with through reflection, debate, and legislative correction. That isn’t going to happen in the near term, either legislatively or through Executive Order.
In fact, I would guess that there will be sniping to undermine effective health insurance and associated social justice issues at least until the 2018 Federal elections. Bits and pieces will be removed, sabotaged, or reorganized to make them ineffective. I imagine lawsuits will be filed to overcome these changes, but if the history of ACA lawsuits is any indication, they will drag on for years and will affect strategies around the appointments to the Supreme Court, as well as undermining access to healthcare.
Michigan’s Move to Integrated Care
One silver lining for Michigan is that the process to move forward with a framework to integrate physical health and behavioral health (DD, SMI, and SUD supports) will not have the complication of big changes in Medicaid and the ACA to make this process even more daunting than it is now. But, the Michigan legislature will be discussing the payment model and policy recommendations from the 298 work group over the next few months.
It is my opinion that the choice of payment model will ultimately determine how successful we will be in implementing the excellent list of policy recommendations that came out of the workgroup. The major payment model components have to do with the roles of Medicaid Health Plans and our current system of PIHPs. Everyone sees the local community mental health systems staying more or less as they are now.
If you would like to get the flavor of the models without dragging yourself through the 500 pages of proposals, I pulled two specimen models out of the 42 submitted that will give you the rough boundaries of the issues involved in choosing a payment model. The two models are The Blue Cross Medicaid health Plan model and the Mid-State Health Plan Model. These are relatively pure versions of the potential payment model paths the legislature could take. There are many variations included in the 42 models submitted, and there are a lot of good pieces in these many models.
Familiarize yourself with the issues, as daunting as that might seem, and let your legislators know what you want in an integrated physical and behavioral health system. Since risk pools are a part of many of the models, you may want to familiarize yourself with the parts of any risk pool and good practice in risk pool design that I described recently (Part 1 and Part 2).