2014 midterm elections: The impact on healthcare reform

Republicans are predicted to take over the U.S. Senate in this year’s midterm elections, but industry watchdogs aren’t predicting any healthcare shakeups in the next term.

The Washington Post is forecasting that Republicans have an 86% chance of winning a Senate majority in the elections, and that Democrats have less than a 1% chance of taking back the House of Representatives. Specifically, the Post’s model predicts that Democrats will win 193 seats in the House-a drop from the 201 held after the 2012 election and the 199 the party currently holds.

Since the passage of the Affordable Care Act (ACA), there have been Republican rumblings of repealing the bill, but industry observers say that healthcare reform is no longer a political priority. Unlike in 2010, when the midterm elections focused on backlash over the ACA’s initial passage, calls for repeal have calmed, replaced by increasing concern over more global issues and the economy.

Read: ACA earns higher scores with physicians

Approval ratings for the ACA increased slightly after the White House announced that more than eight million Americans have signed up for coverage on new insurance exchanges, yet a recent Gallup poll indicates that the program has done little or nothing to change people’s perceptions of the ACA.

If anything, Americans are more pessimistic about the reforms. Gallup’s latest polls indicate that 59% of Americans believe the ACA has had no effect on them, 24% believe the healthcare law has hurt them, and 14% say it has helped them. In comparison, those figures were 70%, 16% and 12%, respectively, in 2012.

Despite the general disapproval of the ACA, however, today’s voters are more concerned about issues such as foreign policy and the economy, along with a recent uptick in worries about immigration. In fact, voters listed healthcare next to last on a list of 11 issues they feel the government should be focusing its attention on.

Predictably, Republican voters oppose the ACA more than Democrats. Gallup predicts that Democratic candidates this year will run on a platform of “keep and improve” in terms of the ACA, acknowledging that there are changes to be made. Republicans, however, have designs to introduce their own healthcare plan, or taking a symbolic vote to repeal the law that would certainly be vetoed by President Barack Obama, followed by more serious ACA amendments, according to analyses by both Gallup and the Kaiser Family Foundation.

Next: Majority of voters support improving the ACA, rather than repealing it

Still, even with majority control of both houses, Kaiser reports estimate that a full repeal of the ACA is unlikely without Republicans gaining a two-thirds majority in each. The American Academy of Family Physicians (AAFP) notes that, at this point in the law’s implementation, a full repeal would likely create more of a mess than either party would want to tackle. Kaiser also indicates that while voters may be disenchanted with the ACA, only 35% would favor a full repeal, while 60% support making improvements.

American Medical Association (AMA) President Robert Wah, MD says the original ACA legislation left a lot “to be determined” and work continues to resolve those issues. He predicts continued scrutiny of the law, but says it would be premature to estimate to what degree the healthcare bill could be transformed by a shift in control of the Senate.

Wah says the AMA also would like to see more clarity for patients about purchasing insurance on the exchanges and the makeup of the networks. “Many people who got insurance for the first time are just now learning the gory details of insurance,” Wah says. “Patients that have not previously had insurance are having to learn all about the fine print, in addition to the big print.” Physicians would like more information, too, specifically regarding what happens when patients don’t pay their premiums prior to the expiration of the ACA’s mandated 90-day grace period.

But the bigger issue for physicians than a political volley over the ACA is the issue of the Medicare Sustainable Growth Rate (SGR). The SGR model subjects physician payment rates to annual cuts and has been a bone of contention for years with repeated, but temporary, fixes.

“We believe we have a lot of momentum from the work that was done last year and this year,” Wah says. “Congress has been challenged by many outsiders observing they haven’t gotten much done. It’s all ready to be done, and they can claim a win if they move on it.”

Wah is confident the momentum will continue through to the new Congress, based on the fact that the $160 billion already spent on patching the SGR exceeds the current cost of repeal. “There’s a lot of momentum and good sound reason for Congress to repeal the SGR either right after the election or right after the new Congress forms,” Wah adds.

Medicaid reimbursement parity is another issue on the table, one that Democratic Senators Sherrod Brown (OH) and Patty Murray (WA) have taken on with a bill introduced in July. The continuation of the provision of the ACA that required Medicaid payments to match Medicare payment rates, expires at the end of the year. Some states have volunteered to continue payment parity, but Brown and Murray’s bill would continue the increased payments for another two years and expand eligibility for them to include to providers such as OB/GYN, nurse-midwives, nurse practitioners and physician assistants, in addition to physicians.

But doctors must meet a variety of requirements to get paid under these programs, and those requirements set the stage for a slew of other topics physicians would like to see addressed by the new Congress. International Classification of Diseases-10^th revision (ICD-10) implementation  likely will move forward without additional delays, the AAFP predicts. There have been several delays already, and lawmakers would be pressured to act by payers who have invested hundreds of millions of dollars in implementation of the code set.

“It’s not a joke about how much money it’s going to cost in time and finances to convert,” Wah says of the transition from ICD-9 to ICD-10. “We’ve been pretty vocal about that issue and we’ve been pretty fortunate that the administration has delayed it numerous times.”

But Wah acknowledges that another delay is unlikely. “It’s not that we don’t want to make a change,” he says. “We don’t want to make an expensive change that won’t improve the care of our patients. The realistic view is that we can’t be banking on the ability to delay it over and over again.”

Wah says AMA will continue to advocate for more flexibility in other programs, as well, including Meaningful Use (MU). “The way MU is currently structured, if you don’t get 100%, you don’t pass. There’s no partial credit,” Wah says.

There are many well-meaning programs under the umbrella of healthcare reform and improving healthcare delivery, but the burden of all these programs together has been a real challenge to physicians, Wah says. Between e-prescribing, MU and the Physician Quality Reporting System, and their incentives and penalties, there is too much burden and too little harmony.

“When you look at all three of them in total, they are all similar but on different schedules. It’s quite a bewildering set of requirements,” Wah says. “What we are pressing for is a harmonization of the requirements.”

Ideally, a system would be developed in which physicians could report all their quality information to CMS once, and CMS could process that information however it needs to, he adds.

Overall, however, Wah says he is optimistic about the midterm elections, regardless of which party takes control in Washington.

“At the top level, we all recognize when there’s an election, there’s an opportunity for change,” Wah says. “Whatever that change ends up being, I believe it will be an opportunity for us to work to make healthcare better for our physicians and our patients.”