Economist: Health care reform not a priority in 2016 election cycle

PHILADELPHIA — Gail R. Wilensky, PhD, an economist and senior fellow at Project Hope, said that health care is not likely to play a central role in the 2016 U.S. presidential election as she delivered the Dr. Raymond C. Grandon Lecture at Jefferson University Hospital today.

David B. Nash, MD, MBA, dean of Jefferson College of Population Health and Dr. Raymond C. and Doris N. Grandon Professor of Health Policy, was direct in his assessment of the 2016 climate in his introduction of Wilensky. “Our nation faces some pretty stark political choices,” he said. “It is important that we have some evidence behind our decision-making. There are few people as qualified to offer advice on this decision as Gail Wilensky.”

Wilensky said that this has been the most challenging election cycle she has faced in more than 2 decades of experience as a health care economist. “We had a 2008 election where the only person talking about a single payer system was Dennis Kucinich,” she said. “All through that cycle, single payer was never debated. However, since the [Affordable Care Act] has been enacted, all of a sudden this is back on the table again.”

2016 candidates’ positions

She noted that Hillary Clinton is a strong supporter of the Act, but that her platform includes the possibility of negotiating drug prices with Medicare. “Medicare has never negotiated a price in its existence,” she said. “The position of Medicare is: this is what it is, take it or leave it.”

Sen. Bernie Sanders (I-VT) is running on the platform of offering Medicare for all Americans, with a single-payer system and no allowance for private insurers, according to Wilensky. “There are claims that his approach will save money, but many democratic analysts question the estimates,” she said. “He is also trying to grant powers to Medicare that were never brought up to me or anyone else who ran Medicare.”

As for the Republicans, Wilensky said that health care reform is not an issue that voters in that party use to decide among candidates in the primary, and therefore the platforms are “always harder to pin down.” They are united in their call to repeal and replace the ACA, she said, but Donald Trump has not offered a lot of detail.

The Affordable Care Act

Of particular interest to Wilensky are attitudes toward the ACA in general. She cited data that 49% of the U.S. population is against it, 38% is in favor, 11% would like to see the program reduced in one way or another, and 10% are fine with it the way it is.

“This has been a mystery to me, why the ACA was so unpopular after it was passed and before it was enacted,” she said. She added that the unpopularity of the Act has increased not among Republicans, but among Democrats, largely because of criticism from Sanders.

However, another reason she cited for the law’s ongoing popularity is the fact that it was passed with a super-majority of Democrats in the Senate. “There has been animosity with how the ACA was passed,” she said. “I am a firm supporter of having less than super-majority in either party. You either get compromise or you get no legislation.”

Despite its unpopularity, outright repeal is highly unlikely, according to Wilensky. “There is no historical precedent for repealing a law like this 3 years after implementation,” she said. “We will see adjustments, but it will not be repealed.”

Moreover, in 2017-2018, a number of new provisions will potentially take hold. These include providing subsidies to people below the poverty line in non-expansion states; smoothing the transition between Medicaid and the exchanges; allowing states to use private insurance for Medicaid without waivers; and eliminating the independent payment advisory board.

Uninsured, Spending and Medical Error

Another focus of Wilensky’s talk dealt with the number of uninsured individuals in the United States. “The latest estimates are that the number is down to 13%, from our most recent data in the first quarter of 2015,” she said. “The reality is that it looks like about 10.5%. Estimates vary.”

However, she was quick to note other estimates that show that by 2026, there will still be 28 million uninsured individuals in the United States. “It is much better than we were, but not as good as we would like to be,” she said. “If we can get to 95% coverage, we can find a way to get providers of last resort to cover the last 5%.”

A companion to this point is the larger-than-expected increase in people covered by Medicaid, from 52 million before the ACA started to 68 million people.

Wilensky also addressed health care spending in the United States. “In my less charitable moments, I’ve described the U.S. health care system as a system designed to spend money,” she said. “We spend enough; we need to spend it smarter.”

Spending slowed down in recent years, but Wilensky attributes this more to the recession than to anything associated with the health care system in particular.

Patient safety issues and clinical appropriateness are other issues that demand more attention, according to Wilensky. “Medical errors are the third leading cause of death, after cancer and stroke,” she said.

Many “perverse” incentives remain in health care, she added. These include tax incentives, pervasive use of third party payment without controls on spending, utilization and technology. “There is also too much fee-for-service reimbursement, and we have a lot of liability issues.”

Wilensky stressed that more focus needs to be placed on targeted prevention. “We need to recognize that obesity is the new smoking,” she said. “We have been hands-down successful at reducing smoking through sustained effort.” She suggested that similar efforts should be placed in preventing and reducing obesity.

Finally, beyond health care, early childhood education, fighting poverty, more food security and equal opportunities for women all should be part of the healthcare agenda. “These are the things that are driving poor healthcare outcomes,” she said.

Gail Wilensky, PhD, can be reached via www.gailwilensky.com.