Doctors Consider Future of Obamacare, Medicare Payment Changes

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By Maeve Allsup

Nov. 7 — The coming year will likely bring some big changes for health-care providers regardless of the outcome of the election.

At a national level, the most prominent health-care issue has been the future of the Affordable Care Act, which Democrat Hillary Clinton has said she will expand and Republican nominee Donald Trump has promised to repeal.

“Any changes to the ACA could alter coverage expansion,” Caroline Pearson, senior vice president for policy and strategy at Avalere Health, a Washington-based consulting firm, told Bloomberg BNA. “From a provider perspective, having more people insured is better.”

Policies that result in fewer people enrolled in the exchanges would have a moderately negative impact on health-care providers, Pearson said. Despite attempts by the Obama administration to stabilize the market, Pearson said she thinks it's likely additional legislation will be needed.

“The Affordable Care Act isn’t going to get repealed, even under a Trump administration,” Chet Speed, vice president of public policy at the AMGA, a trade association for medical groups, told Bloomberg BNA. “There are changes that lawmakers want to make to the act to make it viable going forward.”

One issue that could be addressed as part of the ACA discussion next year is that of provider networks, Speed said. To reduce costs, narrow networks have been created with low-cost providers, but this can exclude providers whose charges may be higher but are delivering better-quality care.

“The concern is that networks are being drawn very narrowly based solely on cost,” Speed said, “which can mean patients are not able to access their preferred providers, some of which they’ve had for years.”

A major concern among supporters of the ACA is insurance companies leaving due to difficulties with exchanges and young Americans not enrolling, Speed said.

Companies want a very viable insurance marketplace, Speed said.

“Lawmakers and insurance companies want to shore up exchanges, and I think there will be a lot of action next year on doing just that, no matter which party is in control of the administration,” he said.

Campaign Priorities

While Trump has stated he would repeal the ACA, the Clinton campaign has focused on the issue of increasing enrollment and making coverage more affordable, Pearson said.

The most prominent issue is how to increase enrollment in exchanges, Pearson said, and there are two general paths that new policy could follow.

“Lawmakers could make changes to the subsidies or to the penalties to try and make it financially more likely that people will decide to enroll,” Pearson said, “or change the benefits design to make coverage more attractive.”

Timing for any of these changes is uncertain, Pearson said.

“Neither candidate wants to address health care quickly, but the realities around the ACA are that there’s not very much time,” she said.

When the next president takes office in January, most of the health-care rules for 2018 will already be done, Pearson said, so any legislation would likely not take effect until 2019, and it would need to be in the works early next year.

However, Democrats in Congress will need Republicans' support to make changes, Speed said.

“The question is, do the Republicans want to help the ACA, and what do they want in return for their support?” Speed said, adding that bipartisan support for these changes may hinge on repealing several ACA taxes.

Lawmaker's View

The political landscape after the election will be an important factor in the changes that are made to the ACA and in how quickly they are implemented, Rep. Phil Roe (R-Tenn.) told Bloomberg BNA.

“It’s going to be a very hard discussion, and it will obviously depend a lot on how the Congress is controlled,” Roe said. “A Republican House and a Democratic Senate would make it very hard to get something done immediately.”

Another upcoming change in health care is the implementation of the 2015 Medicare Access and CHIP Reauthorization Act (MACRA). The law will change the framework for how physicians are paid under Medicare and will offer clinicians two transition pathways.

The majority of clinicians will start Jan. 1, 2017, on the one track that requires reporting quality measures under MACRA's Merit-Based Incentive Payment System. This will give providers a performance score that could raise or lower their Medicare reimbursement. Fewer clinicians—at least in 2017—will qualify to join the second track and become part of an approved advanced alternative payment model that makes them eligible for a 5 percent annual bonus.

“These paths let clinicians pick the right pace for them to participate in the transition from a fee-for-service health care system to one that uses alternative payment models that reward quality of care over quantity of services,” the Centers for Medicare & Medicaid Services said in an Oct. 14 press release about its recent final rule implementing the new reimbursement system (81 Fed. Reg. 77008, Nov. 4, 2017).

While this issue has not been specifically addressed by the presidential candidates, the “transition from service to value” is definitely on the minds of Congress and is an important change for health-care professionals, Speed said.

“Our members are largely concerned with how to create the change needed to be successful under the new framework, and this will be an issue of congressional interest in both chambers,” he said.

The transition will continue at a rapid pace regardless of who is elected Nov. 8, and both candidates are likely to favor nationwide policies, Pearson said.

“The Democrats have established an interest in using their authority to advance more value-based payments, and to do so more on a mandatory and regionally expansive basis,” she said, “and a Trump administration is also likely to favor executive power.”

Although there was overwhelming bipartisan support for the MACRA law in Congress, Speed said, “There are some changes needed to make it more feasible for providers to be successful.”

In an October press release AMGA expressed concern that “CMS does not adequately recognize or reward the providers and systems who have made the investments to improve quality and decrease costs.”

Roe, who serves as co-chair of the GOP Doctors Caucus, confirmed the importance of MACRA and said its implementation is a “nonpartisan issue.”

“Going forward into next year the implementation of MACRA will be a major focus point for the Doctors Caucus,” Roe said. “Our concern is that if we don’t implement this right, we’re going to make it impossible for small practices to survive in rural areas, and if we lose those doctors, rural America loses access to medical care.”

The American Medical Association declined a request for comment on election issues likely to affect physicians.

To contact the reporter on this story: Maeve Allsup in Washington at

To contact the editor responsible for this story: Brian Broderick at

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