Changing the Narrative

As a healthcare economist working for you, one of my jobs is to try to understand how healthcare and health insurance are going to change long before the changes actually happen.

I often find myself sorting through all the narratives coming from policy people and politicians as they talk up changes they want to make to the healthcare law. It’s an ongoing and sometimes frustrating job, but I think it’s critically important to make sure our members can stay up to date, are protected and represented in the halls of Congress.

Last week, we swore in a new president. Now, his choices to lead various federal agencies, including the U.S. Department of Health and Human Services, are being vetted by Senate committees. I watch these meetings, watch the opposing party grilling the new nominees, listen to the language they are using, hear the assumptions they make and see the tools they use to try to pin down nominees they disagree with. It’s quite the dance.

Conditions for Victory

One thing I’ve learned from viewing this week is that the narrative of success in healthcare is changing as we move from the Obama administration to the Trump administration. This implies the incoming administration will also have a new set of “victory conditions” to describe their successes.

A “narrative” is sort of a 30,000-foot level description you control that conveys a big idea. It was quite common for officials of the Obama administration to talk about the success of the Affordable Care Act (ACA) in terms of the number of people covered by some sort of health insurance (increased), or the percentage of the country who are uninsured (decreased).

“So far, the new narrative sounds like this:

Most of the new coverage [gained through ACA] is either Medicaid, which is a failed program, or individual insurance with deductibles so high that many people cannot even afford to use it.”

These were the success statistics Obama administration officials quoted publically most often. Of course, having healthcare coverage is an easily understood goal, so the numbers translate into a clear narrative. But, there is always more than one narrative.

Foundations of Opposition

Buried underneath the Obama administration’s narrative are the foundations of people’s opposition to the ACA. Premiums for people who buy individual coverage who are not poor or sick, have often gone up dramatically. As we showed here at Straight Talk, this happened in markets across the United States.

Also not evident in the Obama administration’s narrative is the fact that the individual markets in many states are quite unstable. It’s worth remembering that nearly two-thirds of Americans live in a county where two or fewer carriers are still selling insurance on healthcare.gov, and one-third of us live in a county with a single carrier left. None of these things signal that the ACA has created stable, affordable markets.

But if that’s the case, why did coverage expand and the uninsured rate drop so much during the same timeframe? These questions are laying the foundation for the incoming leaders of our country in the Trump administration’s new healthcare narrative.

A New Narrative

So far, the new narrative sounds like this:

Most of the new coverage [gained through ACA] is either Medicaid, which is a failed program, or individual insurance with deductibles so high that many people cannot even afford to use it.

“It may be a few weeks before we can tease out exactly what is going to happen. The Pandora’s box of healthcare policy has been opened again, and quickly, by the Trump administration via executive orders. What ends up back in the box — what healthcare insurance looks like before the box gets sealed up again — is not clear right now, not even close.”

Easy to see that if you are going to promote this view, your definition of success and your victory conditions would flow from it, and sound something like this:

We ended the runaway train of rate increases, and we made healthcare much more affordable for regular folks who were getting hammered under Obamacare. We’ve gotten rate increases under control!

I would not be a bit surprised if we start hearing this narrative coming from Washington, D.C.,  shifting the public’s focus from coverage to costs. The incoming party and its agency heads are very focused right now on trying to make health insurance accessible and affordable for more people while also trying to get a handle on costs. A very tall order!

Changing the narrative is hard, and at some point you have to produce data to support your narrative, or nobody will buy it. Despite its shortfalls, the ACA really did add around 14 million more people to some sort of healthcare coverage, and this had the net effect of reducing the country’s uninsured rate to its lowest level in many years. (If you hear someone quoting 20 million, that person is ignoring the fact that around 6 million of them were previously covered but moved to an ACA-type plan, and therefore weren’t truly new covered lives.)

The Obama administration’s narrative has some data behind it. We will be looking for upcoming data to support the Trump administration’s narrative. As we go forward, you should keep an eye on both of these statistics: How many people have healthcare coverage, and how much are they paying for it?

“Despite all the changes on the horizon, remember that until you hear differently the ACA is STILL THE LAW OF THE LAND.”

What’s Next?

It may be a few weeks before we can tease out exactly what is going to happen. The Pandora’s box of healthcare policy has been opened again, and quickly, by the Trump administration via executive orders. What ends up back in the box — what healthcare insurance looks like before the box gets sealed up again — is not clear right now, not even close.

For now, the Trump administration has a few critical decisions they need to make relatively quickly on cost sharing reductions. They have already issued a broad, non-specific executive order that instructs all the relevant healthcare agencies:

To the maximum extent permitted by law, the Secretary of Health and Human Services (Secretary) and the heads of all other executive departments and agencies (agencies) with authorities and responsibilities under the Act shall exercise all authority and discretion available to them to waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the Act that would impose a fiscal burden on any State or a cost, fee, tax, penalty, or regulatory burden on individuals, families, healthcare providers, health insurers, patients, recipients of healthcare services, purchasers of health insurance, or makers of medical devices, products, or medications.

Now, I have no idea what “waive, defer, grant exemptions from, or delay” will turn into in the real world, but you can see the agency heads are already getting their marching orders, even in areas where the agency heads aren’t in their jobs yet.

Despite all the changes on the horizon, remember that until you hear differently the ACA is STILL THE LAW OF THE LAND. The individual mandate has not been repealed or waived. The employer mandate is still in force. All the rules and regulations that tell us how to create insurance policies and what we can and cannot sell are still in force. When that changes, we will let you know right away.

In an upcoming post, I’ll look in more detail at one new policy option, which is being co-promoted by Sen. Bill Cassidy, R-La., called the Patient First Act of 2017, and I will discuss how it would change the ACA and the health insurance marketplace if adopted.

You can count on the fact that I’m watching, listening and expecting the narrative to change. I will be on top of it for you as we move forward.

As it becomes more straight, I’ll be bringing it to you here. Stay tuned!

We’ve updated our Q&A on healthcare.gov, the individual insurance market and the Affordable Care Act (healthcare reform law) in the Trump administration. Read it here.

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