This is the second article in our series on the effect of a “slow repeal” of the ACA, which began January 3, 2017, when Senate Budget Committee Chairman Mike Enzi introduced a budget resolution with instructions to the relevant Senate and House committees to develop a plan to repeal the ACA. The four committees that control healthcare policy have until January 27, 2017, to draft reconciliation bills, which will address the important details, likely including how long it will take to replace the ACA, and which parts of the ACA will be repealed through a budget reconciliation process. On January 4, 2017, the Senate promptly voted (51-48) to begin debate on the procedures to repeal the ACA.

This week’s discussion focuses on the potential impact of the slow-walk repeal of the ACA on physicians.

As detailed in our last article, the hospital industry was vocal in expressing its concerns about any wholesale repeal of the ACA. The nation’s largest physician organization – the American Medical Association – also weighed in. In a letter timed to coincide with Sen. Enzi’s introduction of the budget resolution, AMA CEO Dr. James Madara sent a letter to congressional leaders on both sides of the aisle urging Congress to take steps to preserve health insurance for the approximately 20 million people now insured under the ACA.

Consistent with the AMA’s Vision on Health Reform (November 15, 2016) expressing the core principles and priorities that will guide the association’s advocacy efforts regarding the ACA, Dr. Madara reiterated the AMA’s commitment to continue efforts to cover the uninsured and to ensure any future proposals do not cause individuals covered as a result of ACA provisions to become uninsured. Moreover, although the budget resolution is deliberately silent about the precise contours of what will replace the ACA, Dr. Madara added, “[c]onsistent with this core principle [to make coverage affordable and accessible], we believe that before any action is taken through reconciliation or other means that would potentially alter coverage, policymakers should lay out for the American people, in reasonable detail, what will replace current policies.”

The AMA’s warning against repealing the ACA without articulating a replacement plan highlights the growing feeling among Washington insiders that “repeal” is highly nuanced. With health systems and physicians pressing hard to make sure there is some form of coverage for the uninsured and those currently covered under the ACA, the policy debate will likely turn quickly to a dialogue surrounding the plans that have already surfaced (“A Better Way Health Plan” [Speaker Paul Ryan]; “Empowering Patients First Act” [Rep. Tom Price, HHS Secretary nominee]; “Patient CARE Act [Sen. Orrin Hatch, Sen. Richard Burr, Rep. Fred Upton]; “Improving Health and Health Care” [American Enterprise Institute]; and the “Universal Tax Credit Plan” [Avik Roy]).

The AMA’s Vision on Health Reform underscores that physicians are equally concerned with the administrative burdens of both public and private insurance programs. On October 14, 2016, the Centers for Medicare & Medicaid Services released the final rule implementing the Medicare Access and CHIP Reauthorization Act’s (MACRA) Merit-Based Incentive Payment System and Advanced Alternative Payment Models. A survey of the websites of any physician association (state or federal, primary care or specialty-focused) reveals an uneasy tension about the implementation of value-based care. Moreover, while physician advocates are careful not to conflate MACRA and the ACA as a part of their response to reform efforts, it is likely that physicians will push just as hard for reforms to MACRA, alternative payment models, prior authorization and RAC audits.

With debate beginning in earnest on the fast-track repeal of the ACA, there will be a lot going on in Washington, D.C., over the next three weeks. With the prospect that the ACA replacement process may take as long as two to four years, our advice for physicians, as it was for hospitals, is: Stay the Course – Assess What You Have – Wait and See – Be Alert – And Don’t Be Silent.