Congressional hearing showcases the divergence in the two parties’ views on how to improve U.S. healthcare

• During a recent congressional hearing, Democrats promoted the insurance coverage gains stemming from recent legislation and highlighted additional bills to further bolster coverage.
• One witness said coverage expansion doesn’t address the “root problem” of healthcare costs.
• Price transparency was noted as a solution for addressing the cost issue at its core, although concerns remain about recently implemented rules.

Competing visions of healthcare reform were on display during a congressional hearing this week.

Democrats on the House Health Subcommittee touted coverage gains provided by the Affordable Care Act (ACA) and, more recently, the COVID-19 relief legislation known as the American Rescue Plan. Those expansions can improve access to high-quality care, paving the way for healthier populations and, ultimately, lower costs, various members said.

Republicans countered that subsidies for health insurance represent money misspent when policymakers should be focusing on ways to improve affordability throughout the system.

“Healthcare coverage does not always equal access to affordable, quality healthcare,” said Rep. Neal Dunn, MD (R-Fla.), a surgeon for 25 years before getting elected to Congress. “We’re not better off if more people technically have coverage but still face sky-high deductibles and exorbitant drug prices.”

Building on the progress of the ACA

The March 23 hearing took place on the 11^th anniversary of the signing of the ACA and 12 days after the signing of the new relief legislation. Provisions in the new law are intended to fill in some of the coverage gaps that have lingered in the years since the ACA was enacted.

The Congressional Budget Office estimates that as a result of the new legislation, 2.5 million previously uninsured individuals will obtain coverage through the ACA marketplaces over the next two years. That projection could rise now that the U.S. Department of Health and Human Services has pushed back the expiration of the ongoing special enrollment period from May 15 to Aug. 15.

Democrats used the hearing to showcase 18 bills that have been proposed to further shore up coverage and access, such as through provisions intended to reduce out-of-pocket costs and strengthen Medicaid programs. In one proposal, the Medicaid rates paid to primary care physicians would be increased to match Medicare rates.

Katie Keith, JD, a witness at the subcommittee hearing and associate professor and adjunct professor of law at Georgetown University, said pending legislation should focus on three primary goals:

• Funding outreach and enrollment efforts to enhance awareness of opportunities to buy insurance through the ACA marketplaces
• Protecting consumers from noncomprehensive coverage options, such as short-term, limited-duration insurance plans that are available outside the ACA marketplaces
• Helping states expand access to comprehensive coverage through steps such as lowering out-of-pocket costs, prioritizing health equity and experimenting with auto-enrollment

A different set of priorities

Republicans on the panel preferred to focus on structural healthcare costs during the four-hour hearing. They posed many of their questions to Marni Jameson Carey, executive director of the Association of Independent Doctors, who said the various bills under consideration don’t “address the root problem in our healthcare system, the fundamental reason so many Americans still lack coverage and lack access. The problem is that healthcare costs far too much in this country.”

“If we are truly going to achieve the important goal of making sure all Americans have access to healthcare, we must lower costs,” Carey added. “This is true regardless of who is paying the bill, whether an individual, a private health plan, a government payer or a self-insured employer. Real prices matter, and we need to bring them down.”

Carey’s organization, a not-for-profit trade association that supports independent physicians, promotes systemwide price transparency as a way to address costs. A good first step is to rigorously enforce the transparency rules that took effect this year, she said.

“By requiring hospitals and insurers to make hidden healthcare prices clear, comparable and accessible to consumers, patients could begin to shop and compare prices, and healthcare could begin to function like other competitive markets,” she said.

Physicians want to provide clear information about prices to their patients, Carey said. The problem is they often get significant pushback from health plans and hospitals over concerns that a physician’s posted cash prices could make both an insurer’s contracted rate and hospital prices look bad in comparison, she added.

Trepidation about price transparency mandates

The hospital industry has concerns about the new transparency rules, especially at a time when compliance may divert already-strained resources from the fight against the COVID-19 pandemic.

In an amicus brief filed in July 2020 as part of federal litigation over the transparency mandate, HFMA also cited the “limited utility that the additional administrative burden will have. The price lists that would be produced would be so mammoth that they would be incomprehensible to nearly all patients, who, even if they did understand the lists, would still not have the information they would need to determine what really matters — the patient’s out-of-pocket cost.”

Congress ultimately may need to place statutory authority behind the regulations, Carey said.

“Hospitals are not complying with the rule as it stands,” she said. “We really need machine-readable formats so data innovators can aggregate the data, we can start to shop for prices the way we shop for airline tickets, and the competition will kick in and prices will come down.”

However, the insurance system in the U.S. renders price transparency moot in some situations, including for patients who have exceeded their deductibles or who need high-cost care for which their deductible is irrelevant.

In such scenarios, “Individuals do not have an incentive to shop around for bypass surgery, for instance, even if they have time to prepare for it,” Sen. Mitt Romney (R-Utah) said during a February hearing. “They don’t care whether it costs $10,000 or $100,000 to have bypass surgery.”

Romney cited health savings accounts as a possible mechanism for creating “a true marketplace” for healthcare consumers. HSAs also can be a tool for helping people purchase insurance if they don’t qualify for subsidies.

“Those are some of the ideas that need to be discussed as we try to draw the healthy [people] of all ages back into the marketplace,” Dean Cameron, director of the Idaho Department of Insurance, said during the March 23 hearing. “We think there ought to be some options within the ACA that would openly allow health savings accounts so that those that are healthy can buy less-expensive coverage and set more money aside in their health savings account.”