Expert Q&A: Timothy Jost on the GOP plan, media coverage and angles journalists should be tracking
With the barrage of reporting on the health law changes, we decided to ask Prof. Timothy Jost to share his take on the policy proposals, media coverage, and which under-reported topics health reporters should heed. Jost, an emeritus professor of law at the Washington and Lee University, has written numerous articles and book chapters on health care law and policy, and blogs for Health Affairs.
Q: What do you think of the current media coverage?
A: I think the media is doing a pretty good job of reporting on Republican replacement plans. As I look at the American Health Care Act (AHCA), it’s providing massive tax cuts, particularly for high-income individuals. Maybe we could benefit from a bit more discussion as to who exactly benefits. I’ve seen a number of reports about the tax cuts helping the wealthiest Americans, but I’ve seen very little discussion as to why that’s a good idea.
With respect to the actual changes in the ACA, the main issue is that it moves resources pretty dramatically from older and lower-income people to younger and higher-income people. I think the media has done a pretty good job of reporting on that.
I’m at a disadvantage commenting on media coverage because I read everything! I probably spend an hour to two hours reading media daily.
Q: Do you have any criticism of what you’ve seen so far?
A: One criticism I have is so much coverage is focused on politics within the Republican Party, to a much greater extent than on what the legislation would specifically do.
The most important issue that the Trump administration and Congress need to address in the next few months is the funding of the cost sharing reduction payments and the House’s lawsuit [over Obamacare’s cost-sharing subsidies]. For health insurers, that’s a make-or-break thing for staying in the individual market. I don’t think that’s getting enough coverage.
The other thing is the proposed rules from the Trump administration. We’ll probably get the final rules in late March or early April. Those have gotten far less coverage than they deserve.
Q: What should journalists watch for when reviewing those Department of Health and Human Services rules that could affect Obamacare enrollees.
A: What they do to special enrollment periods, actuarial values, network adequacy, essential health benefits, essential community providers, and open enrollment period length for 2018. There are a number of important issues addressed there.
Two of the biggest complaints about the ACA by the public and the Trump administration have been narrow networks and high deductibles. The proposed rules would do away with federal oversight of network adequacy and would also allow plans to lower their actuarial value, which would raise cost sharing. Here you have two proposals that would worsen the situation that has brought about the most complaints.
Q: Many conservatives argue that states should have more flexibility to design their Medicaid programs than they’ve been allowed so far. That could include changes such as work requirements for Medicaid enrollees, as well as co-pays and premiums. The idea is that these changes would give people stronger incentives to choose lower cost care. What’s your take on that kind of policy argument?
A: For states, there’s already a huge amount of flexibility in terms of optional benefits and categories of coverage. Since the beginning of the Medicaid program, the federal government can grant waivers to states under section 1115 to give additional flexibility. I don’t see that flexibility is an important constraint on the states.
Most Americans now have fairly high-deductible policies — most do have skin in the game. A large body of research now shows that the effect has been that people cut back on their use of medical care. If people knew how to cut out unnecessary care as opposed to necessary care, that might not be a bad thing. But studies show that people don’t fill prescriptions, they split pills, and they don’t go to the doctor when they should. Average people aren’t medically trained and don’t know when they need help and when they don’t. That’s why we have a health care system.
Once you get into the hospital, most people don’t say: “How much does that test cost? If I checked into another hospital, could I get that test done more cheaply?”
Consumers have very little price information except for a narrow range of procedures that are standardized, like LASIK surgery, and are usually not covered by insurance. Price shopping is not possible. There’s been a lot of talk about the Indiana [Medicaid] program, in which people were given these (Personal Wellness and Responsibility) POWER accounts, but a study found that more than half of them either hadn’t heard of them or didn’t know they had them.
Q: What about work programs?
A: Most people in the expansion population already work and most that don’t can’t find work. For a lot of people, the work that they’re doing is intermittent, part-time or they’re laid off easily.
Medicaid has historically not been a workfare program and making it that is a dangerous thing because it’s going to result in a lot of paperwork and expense for the state in trying to keep track of what everyone’s doing. There’s a lot of data on this: People on Medicaid either are employed or trying very hard to find work, or they are people who are essentially unemployable. Requiring them to fill out forms and go look for work is not going to help anyone.
Q: Aside from the health law itself, what other health-related changes are important to watch in the proposed budget?
Public health is a really underreported. One of the things that the AHCA does is eliminate the Prevention and Public Health Fund. That’s been a very important source of funding for public health programs that are very badly under-funded in the U.S., and so I think that’s an important area that needs more focus.
Q: In all your hours reading health articles, what are you most drawn to?
A: Longer pieces that look at issues that are underreported like the public health fund, and pieces that are longer, more thoughtful and more analytical, such as from [Vox’s] Ezra Klein and Jonathan Chait of New York Magazine. Politico, Inside Health Policy and Bloomberg are doing a good job following the details. My own work on the Health Affairs blog is really good (laughs).
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