Reading Elizabeth Warren’s Healthcare Plan, Part 4

Part 1: Quotes directly from Elizabeth Warren’s official website about her healthcare plan, from which I am drawing all of my information for subsequent posts

Part 2: Reviewing her plans for dealing with pharmaceutical prices

Part 3: How she will “improve the ACA” to get her transition to M4A started

I’ve been saying that Elizabeth Warren’s healthcare plans fall into 3 categories:

  1. General details that will apply regardless of how close she gets to achieving Medicare for All (M4A)
  2. Her plan to transition to M4A
  3. Her vision of what M4A would look like if it is achieved

This week I’ll round out the many other general details she mentions that don’t apply to category 2 or 3. I think, given the somewhat low likelihood that M4A will actually be achieved, we could consider this and the two prior posts in this series as the most likely scenario of what our healthcare system will look like with a Warren presidency.

She’s given us quite a variety of details, so let’s just run though them.

She’s going to make some changes to Medicaid (which, as a reminder, is a program run by each state using some government funds), including eliminating some state Medicaid programs’ policies of dropping coverage for silly administrative reasons, having stricter standards for the adequacy of provider networks in Medicaid managed care plans, and she’ll allow more states to do creative Medicaid expansions (using 1115 waivers) even if it increases federal spending.

She wants to improve access to care for rural and underserved patients, so she will reimburse rural hospitals at a higher rate, increase funding for Community Health Centers, increase apprenticeship programs to train up more of the healthcare workforce from those communities, lift the cap on residency spots in rural and underserved areas, and she will increase loan repayment programs for caregivers who work in underserved areas or who work for the Indian Health Service.

On the topic of antitrust, she wants to be stricter. She will appoint stricter enforcers of antitrust laws, block all future mergers unless they can prove that the newly merged entity will maintain or improve care (doesn’t seem like a very high standard, actually), repeal a law (called COPA) that allows for laxer enforcement of antitrust laws for some parties, and she will even go so far as to break up mergers that she thinks never should have happened.

She seems to talk specifically about unions quite often, so she must really want their support (or maybe want to avoid their resistance). Much of it applies to her M4A plans, like allowing them to negotiate moving to M4A earlier and requiring employers to pass along any savings obtained from that directly to the employees, but she will also lower taxes on union-negotiated health plans.

And then there are a bunch of things in the “other” category. I won’t list all of them, but the main ones that stuck out to me reading through all her stuff are as follows:

  • Prevent hospital systems and EMR companies from blocking sharing of medical information
  • Lower post-acute care reimbursement
  • Establish site-neutral reimbursements (this means that a specific service will be reimbursed the same regardless of whether it was provided in a hospital versus an outpatient clinic)
  • Expand bundled payments
  • Establish some standardization for the insurance industry’s paperwork (e.g., prior auths, appeals) and billing processes
  • Create a nationwide all-payer claims database (so we can see what providers are actually getting paid for delivering services all over the country)
  • Ban non-compete and no-poach agreements
  • Lift the cap on residency spots
  • Give grants to states that want to expand scope-of-practice laws so more non-physicians can practice primary care

My assessment: Having now looked at the most likely scenario for our healthcare system under Elizabeth Warren in Parts 2-4 of this series, I would consider it a collection of incremental changes. A few more people will be insured via Medicaid, a few more people will get subsidies to buy ACA plans, a few hospital mergers will be prevented, medications will be a little cheaper, and underserved areas will have a few more caregivers with a little more funding at their disposal.

Don’t get me wrong, these will make a lot of people happier, and that is fantastic. But they won’t make a huge dent in the number of uninsured (unless she re-implements the tax penalty for going uninsured, which I don’t think she’s admitted to yet), and they’ll do even less to affect the other primary driver of recurring efforts to reform healthcare over the last several decades–its cost. High costs are what push budgetary constraints and get politicians riled out about how to reform so that they can spend less on healthcare. High costs of care are what drive insurance prices to such heights that few can buy it without government subsidies, which then causes the uninsured ranks to swell even more.

My recommendation: Have a back-up plan. If the transition to M4A gets stalled, then this is what we’ll be left with, and it’s not going to win any awards. Changes need to be made that enable the cost of care to go down. I have explained those changes in my Building a Healthcare System from Scratch series.

That series also explains that even if M4A is achieved and also succeeds at lowering total healthcare spending (not a guarantee), it will only temporarily bring down the level of spending, but the trend will be largely unchanged, so we’ll be right back to where we were before M4A within a decade or two. Therefore, with or without M4A, her plan is missing the key components that will enable the cost of care to start going down. But I’ll get into that more when I talk about her vision for M4A.

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