Lanhee J. Chen is David and Diane Steffy Fellow in American public policy studies and co-chair of the Healthcare Policy Working Group at the Hoover Institution. Daniel L. Heil is a policy fellow at the Hoover Institution.
President Donald Trump reportedly came close to introducing a health reform proposal last week but pulled back when Republican lawmakers expressed concerns. GOP leaders are now focused on advancing ideas they can agree on as Democrats demand action.
For more than a decade, Republicans have faced the accusation that they have no policy alternatives on health care. Such rhetoric persists because — despite dozens of Republican legislative proposals since the 2010 passage of the Affordable Care Act — their focus has remained on opposing the law rather than promoting their own ideas.
Democrats are right to raise concerns about the shortcomings of our health care system. But the policy idea the government shut down over — extending the ACA’s enhanced coverage subsidies — would have done nothing to address these ills.
Today, patients have fewer choices and ever-shrinking control over their health care purchases. Supply-side restrictions abound, shielding providers from competition. Meanwhile, subsidies and regulations continue to promote high-premium, low-cost-sharing insurance plans that give patients little reason to consider the value of their health care choices. Rising premiums and fewer options are the result.
Now that they have an opportunity to present an alternative, Republicans should advance ideas that put patients back in charge. Change does not need to happen in one comprehensive law. Indeed, the failure of past efforts warns against this approach. Instead, lawmakers should focus on reforms that systematically shift power away from established interests and to patients.
First, lawmakers should expand the supply of providers and services. They can start by repealing the ACA ban on physician-owned hospitals. The stated objective of the ban was to prevent conflicts of interest among doctors when referring patients to hospitals, but it was really a sweetener to existing hospitals to win their support for the ACA by limiting future competition. The actual outcome has been fewer health care providers. In fact, plans for at least 75 new hospitals were canceled because of the ban, limiting patient choices.
Policymakers should also encourage states to eliminate policies that restrict the construction of new health facilities, such as certificate-of-need laws and certificate of public advantage, or COPA, laws. The former require government permission to construct new hospitals or expand existing ones. The latter shield hospitals from antitrust laws. The Federal Trade Commission has long objected to these arrangements, pointing to evidence that they result in less competition and higher prices. Federal lawmakers could encourage their repeal by offering additional federal funds to states that have eliminated these anticompetitive policies or by cutting Medicaid matching rates to states that refuse to eliminate them.
Similarly, provider-driven restrictions on patient access and choice should be abolished. Scope-of-practice rules prevent nurses and other practitioners from performing certain services even if they have the requisite training. The physicians’ lobby argues that these rules are necessary to protect patients, but there is little evidence that these restrictions yield better health outcomes. Again, federal lawmakers should use federal funds to encourage state reforms.
Second, lawmakers should shift control over our health system from insurers to patients. Republican-led efforts to expand access to health savings accounts (HSAs) and individual coverage health reimbursement arrangements (ICHRAs) have already made progress toward this goal. Rather than continue to pay insurers for high-premium insurance plans, HSAs and ICHRAs allow employers to give more money directly to their employees for health care purchases. The One Big Beautiful Bill Act expanded access to HSAs for ACA recipients and relaxed tax rules that prohibited the use of HSA funds for direct primary care arrangements, which allow patients to work directly with doctors to receive and pay for care.
Using the same logic, lawmakers should shift power to Medicaid and ACA subsidy recipients by providing more dollars directly to them rather than to intermediaries. President Donald Trump has already endorsed this idea, but Republicans should make it a reality and coalesce their policymaking efforts around a patient-centered vision.
Rep. Dan Crenshaw (R-Texas) has proposed giving states waiver authority to spend Medicaid dollars on direct primary care arrangements that would give Medicaid recipients more choice and better access to primary care doctors. During the shutdown, Sen. Bill Cassidy (R-Louisiana) proposed redirecting the enhanced ACA subsidies to flexible spending accounts that would belong to ACA plan enrollees rather than being sent through insurers.
Finally, Republicans should consider reforms to federal programs that, while well-intentioned, have largely benefited interest groups. A prime example of this is the 340B program, which was created in 1992 to ensure that low-income Americans have affordable access to prescription medicines. The Congressional Budget Office found that the program has led to consolidation among hospitals and increased federal health spending, with scant evidence that participating providers channel the extra resources toward vulnerable populations. Congress could mandate better accounting for how health care providers use 340B funds and establish stricter guidelines to ensure that benefits get directly to patients, rather than to health systems along the way.
Some of these ideas have previously garnered bipartisan support. And they represent a perspective that moves us away from more opacity and government control of the health system to one where patients are in control.
If Republicans are serious about advancing health reform, there is no shortage of ideas that can lower costs, expand access to quality care and give patients greater control over their own health care.
Democrats started this debate during the government shutdown. Now, the president and his partisans in Congress have an opportunity to pass reforms that can end the discussion and take important steps toward improving our nation’s health care system.
The post Short on ideas for health care reform, Republicans? Here are a few. appeared first on Washington Post.
