WASHINGTON — As President Obama hosted governors from both parties at the White House Sunday night, talk turned from how to repeal the Affordable Care Act to how best to deal with it now that it is law.
As it turns out, there are several bipartisan improvements both fans and foes agree on.
"The whole dialogue on the Affordable Care Act is about people fighting, causing gridlock and a mess, instead of working on something important like wellness," said Michigan Gov. Rick Snyder, a Republican, adding that he had "a lot of issues" with the law. "But it is the law, so I'm trying to work in that context."
Here's a quick look at five things most health experts agree would be improvements on the law:
1. The doctor fix
Since its creation in 1997, the Medicare Sustainable Growth Rate (SGR), which is the way doctors are reimbursed, has been the source of frustration for doctors and politicians. Congress decided that year that physician spending should be limited if it outpaces the rate of economic growth. So far, it has every year. So every year, Congress overrides its own rule because they worry that doctors won't take Medicare patients if the payments are too low. The 1997 law would reduce payments to physicians by 4 to 5% every year. Gail Wilensky, former Medicaid program director under President George H.W. Bush, said the annual battle means doctors don't know how to budget for the future.
"In the past, there seems to have been a lot of focus on just getting rid of the SGR without recognizing that we need to change the fundamental way we pay physicians," Wilensky said. " The real difference this year — the second half of 2013 — is that the Congress has seriously looked at how else you might pay physicians."
A bipartisan payment reform bill has been passed unanimously by the House Energy and Commerce Committee that repeals the cuts, adds an annual increase of .5% from 2014 to 2018, and includes a rewards-and-penalties system that makes it worth doctors' while to save on costs while maintaining quality, she said. The Senate Finance Committee has a similar bill.
2. The family glitch
The "family glitch" is the requirement that people purchase insurance through a spouse's employer if the employer offers it. The law requires that an employer provide affordable insurance, or insurance that costs less than 9.5% of a employee's household income, to an employee. If not, the employee may buy insurance through the health exchanges with a subsidy, if eligible. However, the "affordable" part only applies to the employee, and not his or her family. So, if the employee has affordable insurance, but his employer doesn't provide affordable insurance to the employee's family, the family is not eligible for subsidies.
"The authors of the law wanted people to take advantage of what the employer was offering," said John Arensmeyer, CEO of the Small Business Majority, an non-profit advocacy group. "The problem is if your percentage goes too high, it's not a benefit. I think there is probably bipartisan consensus on that issue."
Health care officials and experts say the fee-for-service payment system must go. Health experts, including Wilensky, have argued that paying a separate fee for each surgery, X-ray and examination leads to more surgeries, X-rays and examinations. The law adds bonuses for hospitals and provider networks that coordinate care to cut costs and increase quality, but there is concern that it's not happening fast enough in Medicare and as well in the private care system.
"Almost every health policy expert feels we need to change from the fee-for-service system," said Ezekiel Emanuel, a University of Pennsylvania bio-ethicist and one of the architects of the law. "Everyone agrees. We need more bundled payment, we need more capitated payment, and we need to push harder on that faster."
That, he and Wilensky agree, will help keep health costs down. These payment methods allow the insurer to pay a set amount per patient or per overall health issue — such as a heart attack — rather than a separate price for each procedure performed or item used. Wilensky said it needs to apply to how doctors are paid, as well. Often, even though a hospital might be paid per patient, the hospital might pay its doctors per procedure, which keeps costs high, she argues.
4. Smooth transition from Medicaid
Analysts say the government needs to ensure there's a smooth process for moving from Medicaid to subsidized health plans if a person's income changes. As it stands now, open enrollment for private plans — through the state and federal exchanges or off-exchange — goes from Oct. 1 to March 31. Beginning in 2014, everyone must have insurance or face a fine at tax time in April 2015. But some people who qualify for Medicaid in January, because they make less than 138% of the federal poverty level, may not qualify for Medicaid in June, because of seasonal work or a full-time job that doesn't provide health insurance but disqualifies a person for Medicaid.
If that happens, Wilensky said, the person will need to enroll in a new network, possibly with new doctors and certainly with new rules. And, she wondered, how easy will it be for a person to enroll in a private plan after he's been dropped from Medicaid, or in Medicaid after dropping below poverty guidelines.
"There are people who may well move back and forth across those lines," Wilensky said. "What's going to happen to their health care networks? If they go off the exchange and into Medicaid, it's not the same network. How disruptive is that going to be to that care?"
5. Transparent pricing
Many employers have moved toward high-deductible health plans, and the bronze-level plans on the exchanges are also popular in the individual market. But they also mean that, if someone goes in for a broken finger, he or she needs to know how much each segment of care will cost — from the consultation to the X-ray to the bandage. Many proponents on both the left and the right say there should be a menu of costs, and that hospitals, doctors' offices and clinics should be much like shopping in a supermarket.
"If you want people to have skin in the game, they need to have better data on quality and better data on cost," Emanuel said. "Everyone agrees on that, but we're not doing it because we're just fighting about repeal of the ACA."
Toby Cosgrove, president of the Cleveland Clinic and the author of a new book, The Cleveland Clinic Way, said better transparency will also lead to better quality if people can compare prices with outcomes, just as they can review the cost and quality of a television now.
Cosgrove, who supported the law and whose hospital has served as an example of how to change payment methods, said he expects to see some movement on the law in the near future.
"I think it will be amended," Cosgrove said. "There's never been a perfect law written in the past, and I don't think this law is perfect."