"What Do You Have to Lose?" How the Country's Current Mood Will Predict Future Sentiments on Health Reform

It’s now been just over a month since the completion of one of the more unforeseen elections cycles in the history of the United States. For political junkies, the exit polls and final vote tallies provided a number of insights about the mood of America. It wasn’t just the presidential result that raised eyebrows, however. A number of “common person” issues emerged with broad support. Populist ballot measures were widely affirmed, with 4 of 5 states gaining greater access to medical and recreational marijuana use. It was a clean sweep in 4 states (both red and blue) that had ballot measures to raise minimum wages. In some areas, there was abnormally high split-ticket voting (in Minnesota, for example) where rural Democrats were voted into Congress, but with strong simultaneous support for President-elect Donald Trump on the same ballot.

Nearly all of the political pundits agree that within the electorate, there was a groundswell of acting out by those who felt left behind. Economic hardship prevails on Main Street despite record-high salaries in the corporate suites and record-high valuations in equity markets. Rural America, in particular, feels beaten down and left behind. If not underemployment or sub—living wages, it’s opioid epidemics ravaging many areas of the country. President-elect Trump (no matter what you believe or feel about his motivations or methods) attempted to tap into this widespread anxiety and status-quo fatigue to champion “the forgotten ones,” even going as far as employing in his politicking a rather cheeky quip: “What do you have to lose?”

Well, it worked. Many individuals out there in “real America” don’t feel like they have much to lose, and now that generalized feeling is bleeding over into health care. I’m always interested in scouring exit polling results because they provide a rare opportunity to survey Americans, in very large numbers, every 2 to 4 years in an effort to approximate voter sentiment on specific issues as they relate to political stripes and perceptions of policies that would otherwise be difficult to ascertain. In this regard, one particular exit poll result caught my eye: almost half of the electorate (47%) said they thought Obamacare “went too far.” Trump beat Clinton 83% to 13% among this group.¹

I’ve written a number of articles for Pharmacy Times’^® publications expressing my view that health reform (little “h,” little “r”) is here to stay regardless of whom is in the White House, owed to the simple economic reality that we will not be able to sustain the long-term growth trend in health care expenditures. It is a mathematical impossibility to continue on as we are and pay teachers and sell goods and services in a global economy. Over the next 2 to 4 years, we are going to see a validation of that reality. Obamacare, or parts of it, may be legislated away, but the fundamental trends (and pressures to contain cost through value orientation) will not abate. We would do well to remind ourselves that MACRA (Medicare Access and CHIP Reauthorization Act), which brought us a permanent move away from fee-for-service toward value-oriented reimbursement models, was passed with widespread bipartisan support. Remember that the commercial sector has taken to, and adopted, many of the payment reform elements of the Affordable Care Act. Remember that the idea of health insurance exchanges came from both partisan and nonpartisan think tanks. Remember that guaranteed issue and preventing insurance companies from denying coverage because of preexisting conditions enjoys support among 70% to 80% of the electorate.

There are large swaths of policy agreement across the aisles of Congress and on Main Street about modernizing the financing and payment of our health care system. The major disagreement lies in who pays for it and the role of subsidies and market-based approaches. So, now what? My bet is that we should expect a continued general trend toward pushing risk and reward to providers and decision making about how the benefit is accessed (spent) by the patient-consumer. This trend predates the election²:

• [In 2016], enrollment in account-based high-deductible consumer-directed health plans reached 29% of all covered employees, up from 25% in 2015.
• More employees have access to less expensive care: 59% of large employers offer telemedicine, up sharply from 30%, and 82% include retail clinics in their plan network.
• Among those with 20,000 or more employees, 28% provided transparency tools through a specialty vendor in 2016, up from just 15% 2 years ago. An additional 62% say their health plan provides some type of transparency tool. —Mercer National Survey of Employer-Sponsored Health Plans 2016

That half of the electorate believed that Obamacare “went too far” was remarkable considering that much of Obamacare’s focus was increasing access to, and reducing the price points of, insurance to the consumer in the face of an average 25% increase in premiums on the federal exchanges³ announced in October (talk about bad timing). So, increases in the premiums on the exchanges had the effect of both creating a duality of “went too far” for some (47% of the elector- ate), but “not far enough” for many others (31% of the electorate).¹ Add to that duality a wind in the sails of small-government advocates for shifting risk and decisions to the patient-consumer and away from insurance companies and government (vouchers, high-deductible plans, health savings accounts), and there will be a potent mix of disruption coming everyone’s way in the health care provider arena.

For decades, health care providers have enjoyed a marketplace that generally lacked the (typically intense) levels of price sensitivity experienced by other sectors of our economy. To date, policies and legislation have largely focused on access to, and the price of, health insurance, not the cost of delivering care. That has generally protected health care providers from downward pressures on reimbursement.

So, what do the providers of care have to lose? The answer: protection against price sensitivity. Better get ready for delivering value—America is losing its patience.

Troy Trygstad, PharmD, PhD, MBA, is vice president of Pharmacy Programs for Community Care of North Carolina (CCNC), which works collaboratively with more than 1800 medical practices to serve more than 1.6 million Medicaid, Medicare, commercially insured, and uninsured patients. He received his PharmD and MBA degrees from Drake University and a PhD in pharmaceutical outcomes and policy from the University of North Carolina. He also serves on the board of directors for the American Pharmacists Association Foundation.

References:

1. Cillizza C. The 13 most amazing findings in the 2016 exit poll. washingtonpost.com/news/the-fix/wp/2016/11/10/the-13-most-amazing-things-in-the-2016-exit-poll. Published November 10, 2016. Accessed November 21, 2016.

2. Mercer survey: health benefit cost growth slows to 2.4% in 2016 as enrollment in high-deductible plans climbs. mercer.com/newsroom/national-survey-of-employer-sponsored-health-plans-2016.html. Published October 26, 2016. Accessed November 21, 2016.

3. file:///C:/Users/ttrygstad/Downloads/Health%20Care%20Current%20Special%20Election%20Issue_11%2010%2016.pdf. Accessed November 21, 2016.