Dancing on the grave of Obamacare: questions

Last week's extraordinary events present an enormous challenge for contemplating the future of healthcare

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I hate to interrupt the festivities, but I have a few questions.

There are one or two little unknowns here. The answers to these questions are matters of life and death to many in the industry, literal life and death to many thousands of patients, organizational life and death to thousands of companies, hospitals and systems. 

Last week’s extraordinary events obviously present an enormous challenge for anyone who wants to think about the future of healthcare. The challenge is far more than simply trying to imagine the healthcare industry without Obamacare, or under whatever Trumpcare will turn out to be. A much more powerful effect will be come into play far earlier: the uncertainty over that future will have reshape the industry before we even get to the actual “repeal and replace” part.

Here are just some of the questions:

For the immediate moment:

• In what way will the new Congress repeal the ACA? Will it repeal “every line” as many Republicans have promised repeatedly? Or will the replacement laws contain any, some, or all of the parts of Obamacare that are uncontroversially popular, such as the reforms of such insurance company practices as rescission, denial for pre-existing conditions, and seriously low medical loss ratios?
• How soon? Will they wait until they can put together a real replacement, and then phase out the ACA and phase in Trumpcare in, say, 2019? Or will they (as Trump and some Republican congressional leaders have promised) just pass a straight repeal on the first day of business and only then turn to a replacement package? Would such a repeal take effect immediately, or would it wait at least until 1/1/18?
• What will happen to the revenue streams that the ACA has brought into healthcare through expanded Medicaid and through subsidized individual insurance?
• How will the industry react to the impending repeal in the coming months (and possibly much longer) before we know both how this will happen and when it will happen?
• Will the exchange insurance markets essentially collapse almost immediately as the concerns about the uncertainty of the future state of the ACA gets telegraphed forward to the business decisions of health plans and the financial decisions of those insured through the exchanges?
• As a result, will we see a drop in revenues to hospital systems far in advance of the actual passage of any repeal and replace law (as early as 1/1/17 if the exchange markets do indeed collapse and millions do not sign up for the coming year)?
• How much of the “volume to value” push from CMS is based entirely on the ACA? Would a repeal-and-replace law reverse all those initiatives and ban any further such attempts?
• Independently of changes in the law, will the political appointees heading up HHS and CMS try to drive policy away from “volume to value”?
• To what extent does the industry perceive that the entire “volume to value” shift is based on CMS policy and not on their commercial payers? Will this perception stiffen the industry’s slow-footed resistance to “volume to value” business model shifts? Since why should they change their business models to accommodate something that they think will disappear?
• Will this on the other hand further embolden the self-funded purchasers of healthcare (employers, pension plans, unions) to get much better deals through the raft of new tools they are starting to use (such as reference pricing, medical tourism, bundled payments, direct pay primary care, etc.), driving the initiative to reduce healthcare costs through the commercial side, rather than just drafting along in the lee of the government initiatives?
• Given how divided the industry is, with a few large aggressive systems actually doing very well, and many others running on a thin edge, will the uncertainty and possibly lower revenues greatly accelerate consolidation? Will we be driving rapidly in this period of uncertainty toward the landscape of “100 large systems” that Ian Morrison talks about?

The uncertainty of this coming political season is greatly heightened by:

• The relative disunity of the new governing coalition, with a President who likes to punish disloyalty facing a Congress run by people who were as minimally supportive as they could possibly be during the campaign, and with Congressional leaders who cannot count on their caucuses to coalesce behind any particular plan.
• The lack of any consensus on a clear, strong, active replacement plan (Yes, I know: HSAs, selling insurance across state lines, yadda yadda. These talking points do not a replacement for Obamacare make.)
• The lack of any history by which to imagine just what Trump is going to attempt or settle for, coupled with expansive promises that would seem to contradict other Republican models for healthcare (such as promises not to touch entitlements like Medicare, and promises to “take care of everybody” coupled with promises to bring the cost way down).

And those are just some of the questions. We are looking at the minimum at several years of deeply disruptive uncertainty across the industry.

Joe Flower is a healthcare futurist and healthcare speaker. This blog was originally published on The Health Care Blog.