HHS Nominee Confirmation Hearings Elicit Few Details

President Trump's pick for Health & Human Services secretary has suggested there are opportunities to advance healthcare reform efforts, but has offered few details as to how, a pair of healthcare policy experts say.

Two confirmation hearings for President Donald Trump's nominee to serve as Department of Health & Human Services secretary have generated more questions than answers about the future of healthcare reform, policy experts say.

Last week, Tom Price, MD, who has served as a Republican member of the House of Representatives since 2005, answered questions for nearly four hours during a hearing conducted by the Senate Committee on Health, Education, Labor & Pensions (HELP).

On Tuesday, he faced an additional four hours of questioning before the Senate Committee on Finance. [View video.]

"We have got to see the details," said Laura Wooster, MPH, interim senior vice president of public policy at the American Osteopathic Association.

"The senators have only seven minutes to have their speech, ask their questions, then give Dr. Price an opportunity to respond," Wooster said.

"We are getting very small soundbites, and it is very hard to determine whether his answers, on the face of them alone, are satisfying or not."

"Should Dr. Price be confirmed, we look forward to seeing more proposals of what he plans to do and how he plans to offer an opportunity for Americans to have access to affordable healthcare," she added.

During Tuesday's hearing, Price avoided providing detailed answers on a host of policy questions, repeatedly saying he would follow the lead of Congress on the setting of policy.

He repeatedly deferred to the will of Congress when questioned by GOP and Democratic lawmakers about:

• The tools he would use to stabilize and improve the individual insurance market
   
• Medicare reform proposals, including privatization of the program and raising the eligibility age
   
• Maintaining the pre-existing condition provision of the Patient Protection and Affordable Care Act (PPACA)
   
• The Trump administration's plan for replacing the PPACA after Republican lawmakers repeal President Barack Obama's most ambitious domestic policy initiative
   
• Increasing research funding for treatment of Alzheimer's disease
   
• Reforming the Indian Health Service
   
• Repealing the so-called Cadillac Tax provision of the PPACA
   
• Finding resources to maintain medical services in Puerto Rico, which faces a deepening financial crisis
   
• Ensuring that all veterans have access to medical care

Price, an orthopedic surgeon, who before being elected to Congress served as medical director of the orthopedic clinic at Grady Memorial Hospital in Atlanta, did offer a handful of specific policy prescriptions during the Senate Committee on Finance hearing.

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He said high-risk pools to provide patients with catastrophic coverage and the pooling of individuals under "the old Blue Cross Blue Shield model" could be components of replacing the PPACA health insurance exchanges.

He committed to extending the Children's Health Insurance Program for at least five years before CHIP expires in September. And he said that the country has been "missing the boat" on promoting telehealth opportunities in rural communities.

Price and several Republican senators signaled their preference for repealing the PPACA and replacing key elements of the healthcare law with market-based and state-directed reform measures.

In response to committee chairman Sen. Lamar Alexander's (R-TN) question about setting goals for repealing and replacing the PPACA, the Price expressed a strong preference for state-based reform efforts over federal efforts. "Folks at the state level, as you well know having served there, know their populations better than we can know them," he said.

In response to a question from Sen. Rand Paul, (R-KY), about the potential impact of legalizing more forms of insurance than were allowed under the PPACA, the Price said he favors offering patients more market-oriented choices for healthcare coverage.

"Choice is absolutely vital; and I know that if we have as a principal and as a goal having patients have those choices, then I believe that patients will select the kind of coverage they want. The choices that ought to be available to them are a full array of opportunities," including high-deductible and catastrophic-coverage plans, Price said.

'A Step Backwards'
Elliott Fisher, MD, MPH, director of the Dartmouth Institute for Health Policy and Clinical Practice, told HealthLeaders that he is highly skeptical of replacing health plans on the PPACA insurance exchanges with a suite of coverage options that includes health savings accounts (HSAs), high-deductible health plans and high-risk pools.

"They are a step backwards," he said after Tuesday's hearing.

"Half of the U.S. population has at least one chronic condition. In any one year, five percent of the U.S. population accounts for 50% of healthcare costs. HSAs are great for people who are not sick," said Fisher.

"HSAs have a serious limitation in terms of their equity. High-deductible health plans also have serious limitations. They discourage patients from seeking care when they need it; and then once people exceed their deductible, they have no incentive to choose care wisely," he said.

There are more promising individual insurance market models for the Trump administration to follow, Fisher said. "Carefully crafted benefit designs that provide minimal barriers to primary care, then offer financial incentives for patients to make wise choices about elective and expensive procedures—with their involvement in the decision about whether to get the service—makes complete sense."

Widespread adoption of California's state-administered PPACA insurance exchange, Covered California, could be the best approach to establishing a sustainable individual insurance market, Fisher said.

Covered California "does several things very effectively. We know that the key element to the success of the exchanges is having as many people as possible sign up—that broadens the risk pool and keeps premiums down." In addition, Fisher said, the California model:

• Makes it "easy for patients to look at health plans."
   
• Requires "health plans to have similar designs."
   
• Is clear: "People are not hood-winked by fake insurance, which was an old problem and still is a problem on some of the exchanges—patients can't tell what the insurance product is, so they choose a low-cost product that does not meet their needs."

As for why the exchanges are failing, Fisher explained that "they were not marketed effectively, the only people who are in the exchanges are sick… [and] plans raise[d] their prices," causing patients to withdraw, and the exchanges to collapse. "Covered California is the opposite."

The Way Forward
Despite their reservations about Price's nomination, Fisher and Wooster are hopeful that the Trump administration and the Republican-controlled Congress can find opportunities to advance healthcare reform efforts across the country and engage key stakeholders in constructive dialogue.

Republicans "could and should support access to much better information," said Fisher. States are experimenting with delivery systems, "but right now, we are not doing enough to learn which of those models of care and which of those policies are really leading to better performance for the American public," he said.

Although the HELP committee hearing on Price's nomination was short on policy details, it was a step forward in the debate over the future course of healthcare reform efforts, Wooster said.

"We are getting a good snapshot. This hearing was kind of a de facto platform for a larger conversation about healthcare reform."