William J. Maloney, MD


Published 10/1/2017
William J. Maloney, MD

Healthcare Reform: Where Do We Go from Here?

AAOS continues to engage Capitol Hill on orthopaedic issues
In the April edition of AAOS Now, I commented that 2017 would no doubt be a major year for healthcare reform. Indeed, the intense focus on repealing and/or replacing the Affordable Care Act (ACA) has occupied much of the legislative and public debate thus far this year.

After initially pulling a bill from the floor for a vote, the House of Representatives in May passed its version of the ACA repeal by a vote of 217–213, with 20 Republicans voting against. In July, the Senate ultimately failed to pass a “skinny” repeal of the ACA that—among other things—would have eliminated the ACA’s individual and employer mandates, removed a tax on medical devices for three years, and granted states more flexibility in obtaining ACA waivers. Proponents of the bill had expected to turn it over to a House-Senate conference committee to forge a compromise measure. Opponents of the bill criticized the process and policy choices that they felt would accelerate insurer defections and increase premiums.

Now, members of Congress are working together on a bipartisan basis to address some important ACA-related issues. This effort is a positive step.

In September, Senate Health, Education, Labor, and Pensions Committee Chairman Lamar Alexander (R-Tenn.) and Ranking Member Patty Murray (D-Wash.) held the first of several hearings on the issue. And in the House, a bipartisan “problem solvers” caucus is looking at a number of different policy solutions. Legislators acknowledged there are issues with the American healthcare system but commented that their immediate goal was to give Americans the peace of mind that they will be able to buy health insurance for next year. House Ways and Means Health Subcommittee Chairman Pat Tiberi (R-Ohio) is, according to a recent press release from the subcommittee, also looking to “deliver relief from regulations and mandates that impede innovation, drive up costs, and ultimately stand in the way of delivering better care.”

In addition to reviewing the Academy’s position statement on “Principles of Health Care Reform and Specialty Care,” we sent a letter earlier this year to the Senate expressing several healthcare priorities, including preservation of the autonomy of the physician-patient relationship, reduction of the current regulatory burden, and the importance of increasing access to care for all patients. We explained that affordable access to appropriate specialty care is paramount to achieve quality health care, and that “patients must have access to the right treatment, by the right healthcare professional, at the right time.”

AAOS also submitted comments to the House Ways and Means Committee on regulatory areas of concern, which touched on the need for surgical specialty advanced alternative payment models, better Medicare Access and CHIP Reauthorization Act (MACRA) reporting, and more.

We will continue to interface with members of Congress on areas of concern to the orthopaedic profession as these conversations move forward.

While a current bipartisan plan being debated by Congress does not address AAOS priorities like medical liability reform or repeal of the Independent Payment Advisory Board, the plan seeks to address the goals stated by Sens. Alexander and Murray by some combination of the following potential means:

  • making cost-sharing reduction payments to insurance companies
  • creating a “dedicated stability fund” for states
  • exempting small businesses from the “employer mandate”
  • repealing the medical device tax
  • allowing people older than 30 years to enroll in catastrophic health plans
  • making changes to the state 1332 waiver program
  • providing changes to allow insurers to sell across state lines

Another proposal would allow states to offer a “buy-in” to the Medicaid program on ACA exchanges and seeks to align Medicaid reimbursements with those of Medicare. Still, others are specifically concerned with those areas of the country in which there are limited or no health plans to sell coverage on the ACA market­places. Of course, like many debates these days, much of the success of these proposals could come down to how Congress would pay for the changes.

Finally, as of mid-September, Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.) are discussing another attempt for a partial repeal before the reconciliation option ends on Sept. 30, 2017.

At the same time, state and local groups are searching for solutions they can advance without action from the federal government. Further, President Trump’s administration is making significant regulatory changes designed to reduce the regulatory burden on physicians (see “AAOS Commends CMS for Important Changes to Bundled Payment Models” on page 20).

AAOS has been in regular contact with the Department of Health and Human Services and the Centers for Medicare & Medicaid Services (CMS) related to these efforts. A recent letter sent by AAOS specifically addressed areas of improvement that are needed under MACRA, as well as issues related to the ban on balance billing, access to Medicare claims data for qualified clinical data registries, and translation and interpreting services required by the ACA. You can find this letter and all our communications online at www.aaos.org/dc.

“With the implementation of CMS’ Quality Payment Program under MACRA, as well as numerous other regulatory changes, physicians are navigating a complex new reporting system,” the letter states. “Indeed, many are still working to understand the new requirements and prepare necessary infrastructure and education.” This dilemma is a concern we continue to hear from AAOS fellows and one that we are addressing through legislative and regulatory changes as well as educational efforts.

Although the path forward remains uncertain, it appears overall healthcare reform will continue to be a focus as legislators and regulators alike seek to stabilize markets and improve access to care.

Additionally, work on other healthcare priorities continues. For example, the House recently passed vital medical liability reforms as well as AAOS-supported legislation that will better equip medical professionals who travel with controlled substances. Congressional committees passed bills to increase access to foot and ankle care for veterans and discussed Medicare legislation.

AAOS also continues to urge Congress to continue funding for orthopaedic research programs in the Department of Defense and at the National Institutes of Health. These efforts are all very important and we cannot lose sight of them amid impassioned debates that will surely, and necessarily, continue.

As I’ve said in the past, despite our different practice settings and varying political preferences, all aspects of our professional lives are affected by the legislative and regulatory decisions made in Washington, D.C. We must speak out about issues that affect our profession and patients’ access to care. As these debates continue, your AAOS leadership and AAOS DC office are available to review your concerns and answer questions via email at dc@aaos.org or by phone at 202-546-4430. We will also provide tools and information needed to manage your practice during these periods of change. You can find more information on these issues online at www.aaos.org/dc and on Twitter at @AAOSAdvocacy.