Reflections on Repeal and Replace

twitterAmidst discussion of repealing, delaying, and replacing the ACA, what’s ahead for health reform is uncertain, but may be informed by reflection on what’s gone before.

In January 2000, the National Academy for State Health Policy (NASHP) convened a bipartisan group of state health policy leaders to discuss lessons learned from 25 years of state health reform. That report, which we are rereleasing today, addressed many of the reform strategies being considered as Congressional leaders debated the future direction of our nation’s healthcare system. The report concluded “What is needed now, at this critical juncture, is a public commitment, a clearly articulated social contract, to guarantee health coverage for all Americans. Absent that, future reforms will continue to fall short of the mark.”

Assuredly, times have changed and ideas put forward in years past can certainly be updated or revised.

Nevertheless in re-reading this document, I was struck both by how many state initiatives have informed federal policy but also by how advances made by one administration and legislature were rolled back or repealed by another, creating a “policy pendulum” generally driven by ideological opposition rather than evidence of failure. This has perpetuated instability and inefficiency across our health care system, as governments and health systems adjust to changing requirements. As we contemplate the future of the ACA, which ultimately passed without bipartisan support, and a repeal effort that may also receive only one party support, the plea of history – to find our way to a sustainable reform we all can embrace – seems all the more important.

Our report, Access for the Uninsured: Lessons from 25 Years of State Initiatives, notes, “Sustaining reforms in a political environment and with balanced budget requirements is a challenge. Building sustainable reforms takes time. Securing enough votes to enact a new law is not enough. Building solid consensus for reform is critical to assuring its sustainability. Providing incremental reforms in which consumers see immediate results and benefits builds public support.”

The ACA has lowered the rate of uninsured to historical lows and elements of its reforms have broad public support – maintaining coverage for children on parents’ plans to age 26; eliminating waiting periods for pre-existing conditions; eliminating lifetime limits and the ability to rescind insurance coverage and, for the 20 million people receiving financial support, providing affordable coverage. Even the most zealous defenders of the ACA recognize that it is a work in progress and needs some reform. Could this be the starting point of the debate ahead?

Importantly, the ACA required substantial investments in new infrastructure by health plans, providers, and states. One cannot unring this bell…to undo and revise all that work to implement what might be an entirely new approach will take time and resources. And it will test the good will of those who have responded to the demands and incentives provided by the ACA –consumers, insurers, employers, providers, and states. The resulting uncertainty and disruptions in the markets have been well articulated and their impact can be profound.

Watching state efforts over the last 40 years to achieve what the ACA has done in much less time makes me wary. Will we revert to ping pong policy – enacting a reform, repealing it, enacting an alternative, only to repeal that? Or will we find a way forward to reach a clearly articulated agreement that can deliver an efficient and effective healthcare system to our nation’s consumers and those who serve them? The opportunity is there if the Congress and the Trump administration can find it.

Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the Foundation.