What do doctors think of the nomination of Representative Tom Price?

In the days since Rep. Tom Price was named as President Elect Trump’s pick for Secretary of Health and Human Services, more perspectives have emerged. The American Medical Association (AMA) and the Association of American Medical Colleges (AAMC) both issued strong statements of support for the nomination last week. Based on Rep. Price’s record, it is likely that one of his main goals will be to reduce the role of government and regulation in the practice of medicine. This is why some doctors suggest his nomination might be good for doctors, but bad for patients. Based on a recent survey of nearly 1,100 physicians, physician views are mixed:

46% of physicians feel generally positive about Dr. Price, 42% feel generally negative, while 12% are neutral. The survey also asked physicians to indicate whether Dr. Price would improve medical practice conditions for physicians … (46%) believe Dr. Price will improve practice conditions, 34% indicated he will worsen them, and 20% are neutral.

In contrast, the outlook is a little worse for patients:

(47%) believe Dr. Price will detract from the ability of patients to obtain access to quality care … 42% believe he will improve the ability of patients to obtain access to quality care, while 11% remain neutral. [emphasis added]

Over 5,000 physicians from around the country have signed a petition declaring that the AMA’s endorsement “Does not speak for us” and medical students have spoken out as well, stating Dr. Price will “endanger medical institutions and policies, as well as jeopardize our medical education and the very practice of evidence-based medicine.”

So, what else might providers who oppose the nomination be concerned about? Let’s revisit some more details about Rep. Price’s Affordable Care Act (ACA) replacement plan, Empowering Patient’s First.

Remember last week’s blog post about how his plan would treat pre-existing conditions, namely that if individuals did not have continuous coverage they could have their pre-existing conditions excluded from coverage and be charged more in premiums? (This is explicitly prohibited by the ACA). Well, that is precisely why high-risk pools are needed. President Elect Trump highlights the role for these high-risk pools in his health care plan:

The Administration also will work with both Congress and the States to re-establish high-risk pools – a proven approach to ensuring access to health insurance coverage for individuals who have significant medical expenses and who have not maintained continuous coverage. [emphasis added]

What are high-risk pools, and how do they work?

Now, high-risk pools are not new. They are often proposed as a way to provide health care coverage to sicker, uninsurable people (i.e., people with costly pre-existing conditions) outside of the traditional health insurance system. Pre-ACA, people with pre-existing conditions seeking coverage in the individual market (i.e., not through their employer) would be at greater risk of being uninsured. So, high-risk pools were used as a way to provide insurance for this effectively uninsurable population. According to the National Conference of State Legislatures (NCSL), between 1976 and 2009, 35 states established high-risk pools.

Are high-risk pools really a “proven approach”?

The relative effectiveness of high-risk pools is debated. Proponents argue they reduce premiums for consumers, and allow health insurance markets to stabilize. Opponents suggest they are not viable because they are too expensive to administer, expensive for consumers to purchase, and offer inadequate benefits. For example, pre-ACA, many of the state high-risk pools had higher premiums compared to the non-group market, and offered plans with higher deductibles (i.e., the amount you pay out of pocket before coverage kicks in). In 25 states, the plans with the highest enrollment had deductibles over $1,000. Because of this, enrollment is often low. For example, talking about high-risk pools pre-ACA, health policy expert Karen Pollitz said, “You could almost invite some of these pools over for dinner…They’re really dinky. There are only six that have more than 10,000 enrollees.” Opponents suggest insurance works best when the risk (and the cost) is spread across the population.

Case in point, high-risk pools were used as a temporary transition program when the ACA was initially rolled out to provide protection for sicker people before the private insurance reforms kicked in. Costs for the Pre-Existing Condition Insurance Plan (which ended in 2014) turned out to be significantly higher than expected. So, experts agree, funding of these high-risk pools is critical.

Importantly, Representative Price’s plan funds the high-risk pools at a significantly lower rate than Speaker Paul Ryan’s A Better Way plan: Price includes $1 billion a year while Ryan includes $2.5 billion per year (or $25 billion over 10 years). Funding here matters. A recent analysis by the Center on Budget and Policy Priorities explains some of the funding challenges with high-risk pools:

States’ experience with state high-risk pools before the ACA shows that even the high premiums that the risk pools charged covered only about half of the cost of operating the pools. The rest had to come from public support, such as state general revenues or premium assessments on insurers. Unless that support was substantial and rose significantly over time, states eventually had to scale back these pools to keep costs from spiraling out of control. States sharply restricted enrollment in the high-risk pools, set premiums further above what many families could afford, and/or scaled back coverage.  Only a little over 200,000 people in the entire country were enrolled in such pools in 2011. 

So, in these new replacement plans, high-risk pools are supposed to act as a safety net, but their feasibility and effectiveness is in question.

Still to come:

  • How government sponsored tax credits would work in Representative Price’s plan compared to the ACA.
  • Price’s plans for Medicare and Medicaid.

And implications of the Trump Administration’s leadership appointments for health care, addressing:

  • The power of the Secretary of Health and Human Services to erode the ACA without assistance from Congress.
  • Insights into Trump’s choice of Seema Verma to head Centers for Medicare and Medicaid Services (CMS).