WASHINGTON -- Tom Price, MD, former Secretary of the Department of Health and Human Services (HHS) and an orthopedic surgeon, described the "stumbling blocks" to Affordable Care Act (ACA) repeal, the threat of government over-regulation, and the opportunities states have to tailor their own healthcare systems to their constituents' liking, in an address at the on Tuesday morning.
Price also criticized the GOP-led Congress for repealing the individual mandate but doing little else to repeal or reform the ACA, suggesting that action might do more harm than good.
Price resigned from his position as HHS Secretary in September following concerns raised over his use of private charter jets and military aircraft. He made no mention of his resignation on Tuesday.
"It's good to be back. I know that each and every one of you are here because everything in healthcare is moving along just swimmingly," Price said, his characteristic sarcasm on display.
Despite that gloomy introduction, he stressed that now is "a time of opportunity" for stakeholders to help fix a broken healthcare system.
But first, ACA repeal.
"From a policy standpoint, the repeal-and-replace battle last year was kind of the height of political frustration. Wasn't it? ... It really is sad that we find ourselves at such an ideological split as it relates to healthcare," he said.
Price credited the failure of repeal to "two big stumbling blocks" -- Medicaid expansion and the individual mandate. Both of these issues either needed to be resolved or set aside, he noted, in order to find "common ground" on repeal.
"Obviously we weren't able to do that," he lamented.
Medicaid expansion was set aside, but the individual mandate was repealed via the budget bill with its associated penalty slated to end in January 2019.
"That may help, but it still is nibbling at the side," he said of the mandate's repeal.
"There are many -- I'm one of them -- who believe that that actually will harm the pool in the exchanges market, because you'll likely have individuals that are younger and healthier not participating in that market, and consequently that drives up the costs for other folks within that market," he added.
ACA Now and in the Future
In 2018, the costs of the benchmark silver plans on the ACA marketplace rose about 36%, he said.
"But it looks like the market is actually stabilized in the area of the ACA," Price said.
But he also argued that 11 million people enrolled in the exchanges tend to have more expensive healthcare costs and that the exchanges may have become a de-facto high-risk pool "without the efficiency or the true planning of a high-risk pool."
As for future repeal efforts, any such actions will likely be regulatory rather than legislative, he said.
Waiver programs -- 1115 for Medicaid and 1332 for the exchanges -- are a "great opportunity" for states to design healthcare that suits their constituents needs, he added.
But if a "legislative fix" does advance, it will likely be "something like the Graham-Cassidy bill."
Price described the Graham-Cassidy bill as rolling up federal healthcare payment streams -- Medicaid, Exchange payments, Disproportionate Share Hospital payments, Children's Health Insurance Program -- and "plus it up" via a formula. Finally, states would decide how to use the funds.
"Politics, I think, will likely get in the way of that in the near-term," he said adding that, in his view, "both parties" want to wait until after the November elections before attempting any more big changes.
Price also briefly highlighted a federal lawsuit, in which since the individual mandate has been repealed. (The mandate will be repealed in 2019.)
"I don't know what the court is going to do with that," he said. But he expects the case will ultimately land in the Supreme Court this term or next, he added.
The Status of Medicaid Expansion, Medicare
With regard to Medicaid expansion, Price highlighted that many "red" states -- including Utah, Idaho, Nebraska -- are proposing their own Medicaid expansion ideas.
"These are states that ... don't necessarily see a solution coming out of Washington, and consequently many of them ... said 'why are we leaving this money on the table?'"
He suggested that waivers may be the vehicle for designing a "more efficient" Medicaid system.
Price noted that state flexibility also helps Blue States, citing New York and California's consideration of an individual mandate and a single-payer system, respectively.
"That kind of flexibility may be the wisest way to proceed from a public policy standpoint to allow states the opportunity to figure out what works best for their citizens," he said.
With regard to Medicare, Price said that the program would remain a challenge, but he "remains an optimist" overall about constituents' rethinking the broader healthcare picture as mandatory costs like healthcare squeeze discretionary funding in other sectors.
"Americans always do the right thing after exhausting every other possibility," he said, quoting Winston Churchill. "I would suggest to you that we are close to having exhausted every other possibility in healthcare. So, we must be about to do the right thing."
Government Regulation
Price took the opportunity to criticize the government's heavy hand in healthcare. Noting that while regulation is necessary, it shouldn't be so burdensome as to stifle innovation.
As an example, he cited a heart valve made by Edwards Lifesciences that was approved in more than 40 countries before it gained FDA approval, despite being invented in the U.S.
He acknowledged that FDA Commissioner Scott Gottlieb, MD, is currently working to streamline the approval's process.
The former HHS secretary also described examples of government overreach in payment models. He stressed that certain innovation programs in the past targeted to too broad a patient population or too broad a geographic base.
"You have to ask yourself the question about whether or not that really is a pilot ... or whether that is in fact the government telling folks how and when to practice medicine."
(When he was HHS Secretary, he began to walk back some of these initiatives.)
The "poster child" for government over-regulation is competitive bidding for durable medical equipment, he said.
"What we have seen is, it has actually decreased some of the accessibility to services ... especially in rural areas."
Payment Reform, Artificial Intelligence
Also in the vein of payment-delivery reform, Price said that alternative payment models are needed, but that the value of services must be taken into account.
He noted that "quality" healthcare may mean different things for different patients, even those with the same diagnosis but different comorbidities or challenges.
"What that means is that patients are unique and it's important that the system recognizes the uniqueness in new patients, so that the measures that are used to determine quality are actually real and reliable."
With regard to the workforce, Price noted that the nation has 50,000 to 100,000 less doctors than it needs, depending on what study one reads, and that "physician burnout is real."
"The average retirement age for docs is getting lower, and the average disability rate for docs is increasing. There's a reason for that," he said, pointing to the administrative burden on doctors as one of the causes.
In a curious twist, for an individual who frequently points to technology as a barrier, Price also briefly touched on the potential of artificial intelligence in medicine: "Millennials ... I think will demand that these devices be used ... I find it incredibly exciting that they are going to have real-time information about their own healthcare to then be able to share it in a much more informed manner."