Our Predictions for Another Unpredictable Year

Who could have predicted this year, really?

Here at the Colorado Health Institute, we expected that the new Trump administration, combined with Republican majorities in the House and Senate, would bring a swift end to the Affordable Care Act.

But we’re closing in on the 2017 finish line, and the ACA is still limping along. That’s a surprise. It’s also surprising that the ACA’s individual mandate was killed in the tax reform bill. We didn’t see that one coming until just before it happened.

Closer to home, we were pretty sure the Colorado legislature would find a way to keep the Hospital Provider Fee and use that money to continue funding health programs. That happened.

So it’s fair to say that 2017 was a year of uncertainty in Colorado health policy circles.

Will 2018 be an easier year to predict? Probably not. But Team CHI are not quitters.

We offer you our health policy predictions for 2018. If you have ever seen a CHI presentation, you know that we always begin with our three bubbled-up takeaways. In that spirit, here are our three biggest ideas:

1. The Affordable Care Act is not out of danger. Teresa Manocchio predicts the Trump Administration will continue to chip away at its provisions, often through regulation.
2. Watch for continued merging and consolidating among the state’s health care players. The question: Will this be good for consumers?
3. State-based solutions to high insurance prices will be in play. Several of our analysts have thoughts on how this may happen.

And when it comes to Colorado’s 2018 gubernatorial race, we have competing predictions.

Me: Colorado will elect a woman as governor, the first time in its 142-year history. Both parties are fielding strong, competent, qualified female candidates.

versus

Michele Lueck: Female gubernatorial candidates suffer losses in party primaries. Two white men square off to be Colorado’s next governor.

Check back on Wednesday, November 7, to see who was correct.

Without further ado, this is what we expect in 2018.

Karam Ahmad, Research Analyst:

1. Increase in pharmaceutical companies merging and acquiring. As many prescription drugs are set to lose their patents over the next decade, pharmaceutical companies are likely to grow through mergers and acquisitions.
2. Denver will narrowly pass a supervised-injection-facility bill to reduce the spread of infectious disease like hepatitis C and drug overdoses, coming at a time when heroin-related overdose deaths have reached an all-time high in Colorado.
3. Increased coordination of wildfire prevention and education as Colorado sees another dry year and looks to California as a cautionary tale.

Jeff Bontrager, Director of Research on Coverage and Access:

1. Congress will pass a tax bill in 2017 that repeals the individual mandate. (Editor’s Note: Jeff didn’t cheat. He wrote this before the bill passed. In fact, he was the first to submit his predictions.) The repeal and the failure to stabilize insurance markets will lead to greater uncertainty in the individual market, driving more insurers to depart the ACA exchanges.
2. States will face a financial pinch. Congress will figure out a way to continue the CHIP program, but at a lower federal share than the current match.
3. State legislation passes, and Denver City Council narrowly approves, a supervised injection site for heroin users. But not without challenges and controversy.

Ashlie Brown, Director of the SIM Extension Service:

1. Many of the major provisions of the ACA will survive 2018. But the individual mandate will not. (Editor’s Note: Ashlie also write her predictions before the tax bill passed.)
2. Proposals from the U.S. House and Senate will return to Medicaid block grants. CHI will dust off our previous work on this topic to examine the new proposals.
3. Programs coming out of the Center for Medicare and Medicaid Innovation will focus more on cost containment and offer less flexibility to participants. The Colorado State Innovation Model and the Accountable Health Communities Models will continue as planned, but they will be the last federally funded programs to openly address the social determinants of health for years.
4. The Prevention and Public Health Fund will be gutted in budget negotiations. This will leave state and local agencies scrambling for the remaining dollars.
5. Three more states will legalize medical or recreational marijuana. Voters in Michigan, Missouri, Oklahoma, and Utah will weigh in at the polls, but one of these initiatives will fail.
6. Someone will pilot a self-driving ambulance. Local officials shut this pilot down.
7. The repeal of net neutrality rules will dampen ambitions and investments in telehealth. Nevertheless, telehealth adoption will continue to slowly increase across the country, especially in rural America.

Alex Caldwell, Associate Director of Program Development and Analysis

1. Health insurance premiums will continue to climb, especially in Colorado’s mountain regions. The state legislature will consider a reinsurance plan to address those high costs. It will be popular on both sides of the aisle. But the cost to fund the program will be so high that it will fail in the legislature, at least the first time around.
2. Like the CVS and Aetna merger in 2017, we’ll see more vertical mergers crossing traditional industry lines. So think insurers merging with provider groups and pharmaceutical companies merging with hospitals.
3. Both public and private entities across Colorado – from philanthropic organizations to state agencies to the Medicaid program – will change the way they address big public health issues like behavioral health problems and substance use. They will shift investments from treatment and “downstream” efforts to prevention, “trauma-informed care,” mental health promotion and preventing adverse childhood experiences (ACEs).

Chrissy Esposito, Data Visualization and Policy Analyst

1. The number of attempts to dismantle the ACA will decrease in 2018. This will mostly be because Congress will shift its focus to campaigning.
2. I’m assuming the tax bill is going to pass, and the mandate will go away. (Editor’s Note: See above.) I can see the number of insurance carriers continuing to decline in many counties.

Deb Goeken, Vice President of Communications

1. Colorado will elect a woman as governor, the first time in its 142-year history. Both parties are fielding strong, competent, qualified female candidates.
2. Consolidation in the health care market in Colorado will continue at an even faster clip. Will this be a good thing for those of us who consume health care? Color me skeptical.
3. Denver’s housing prices will reach crisis levels. The influx of twentysomethings will slow, and the exit of lower-income and diverse residents will continue.

Joe Hanel, Associate Director of Strategic Communications

1. Spring: Health insurers on the individual market nationwide request large increases in response to lackluster enrollment. The Trump administration shortened the open enrollment period by half, to just 45 days. In Colorado, enrollment was strong, but insurers still request large increases on the belief that 2019 enrollment will crash when the individual mandate is no longer enforced.
2. Winter through late summer: Speaker of the House Paul Ryan leads the charge to roll back the size of Medicare and Social Security. But it becomes apparent the plan will not survive the Senate.
3. December: Major parts of the Affordable Care Act survive another year. Medicaid expansion, which resulted in the largest coverage gains, remains, as Congressional Republicans lack the votes to repeal it.

Emily Johnson, Associate Director of Economic Analysis

1. Proposals to increase price and cost transparency will garner support as a way to reduce health care costs. They won’t work.
2. One year from now, we won’t have a public option . . . but it will start to feel like a real possibility.
3. Repeal of the individual mandate will have almost no impact on uninsurance rates.

Michele Lueck, President and CEO

1. Colorado state legislature considers but does not pass a bill sanctioning a Colorado specific individual mandate. It loses along party lines.
2. Female gubernatorial candidates suffer losses in party primaries. Two white men square off to be Colorado’s next governor.
3. Colorado health philanthropies combine resources to cover Colorado CHP+ kids for 60 days, while Congress struggles to pass legislation reauthorizing the program.
4. The Broncos have a better season.

Teresa Manocchio, Policy Analyst

1. The assault on the ACA is not over. It will continue via regulation.
2. Federal public health funding will be cut, and Colorado will have tough choices to make as a result.
3. Heroin overdoses will continue to rise through 2017, while prescription opioid overdoses will tick down slightly.

Allie Morgan, Associate Director for Legislative Services

1. Four of the six bills recommended by the Interim Committee on Opioid and Other Substance Use Disorders will become law. The others will prove too controversial and/or too expensive to pass the full legislature.
2. After extensive debate and review of a recent study by the Division of Insurance, Colorado will move forward with a request to the feds to create a state reinsurance program, similar to the one that’s made headlines in Alaska.
3. Several state races will come down to the wire, but Democrats will benefit from recent momentum and ultimately flip control of the Senate, resulting in an 18-17 majority and control of both chambers of the state legislature.

Ian Pelto, Research Analyst

1. With entitlement reform next on the GOP’s agenda, I think we can expect many of the same Medicare and Medicaid reforms proposed in 2017 to resurface in more strategic ways. Instead of lumping all of them together, the GOP will have a better chance passing one or two of these reforms under the broader scope of “entitlement reform.”
2. At the state level, I would expect to see a lot more legislation focused on regulating new models of care and expensive drugs and treatments now that the Hospital Provider Fee has been removed from the budget.

Rebecca Rapport, Program Manager SIM Extension Service

1. Local communities will strengthen their efforts to address the opioid epidemic. They will increase resource-sharing among different professions and people. Regional Health Connectors (RHCs) are supporting many of these efforts. (Editor’s Note: Rebecca helps to support the state’s RHCs in her role as a program manager for the SIM Extension Service.)
2. There will be increased coordination between primary care and behavioral health. This will happen at the statewide level in phase two of the state Medicaid program’s Accountable Care Collaborative. On the local level, RHCs help connect these sectors in their communities.
3. All eyes will be on sustainability planning for initiatives created by the ACA as funding appropriated through 2019 begin to sunset. Statewide and local partners will develop sustainability plans for work started by efforts such like SIM.

Sara Schmitt, Director of Community Health Policy

1. Tax revenues from retail marijuana sales will grow in 2018, but at the slowest rate since 2014.
2. Colorado will use the 2018 ballot for health policies, including another city passing a sugary drink tax following Boulder’s successful 2016 campaign.
3. Average school immunization statewide rates will still hover at about 93 percent up-to-date despite new transparency policies, including requirements for school immunizations rates to be posted publicly.

Edmond Toy, Director

1. The state legislature will pass a bill to start the process of creating a reinsurance program to help improve the affordability of insurance for those buying on the individual market.
2. Efforts to move Colorado to a single geographic rating system — a policy that could bring down insurance prices for some, but raise prices for others — will stall after failing to achieve a broad consensus across the different regions in the state.

Jaclyn Zubrzycki, Communications Specialist

1. Colorado’s legislature will pass, or at least consider, a bipartisan price transparency law that requires hospitals and doctors to disclose the costs of services.
2. Colorado will struggle to figure out how to maintain or replace Arapahoe House — Colorado’s biggest substance use treatment facility. Smaller facilities will open, but there will still be questions about cost, quality and the best ways to help with substance abuse.
3. Coloradans will continue to embrace alternative approaches to health — everything from marijuana to Himalayan Salt Lamps to tinctures to bodywork. More researchers will examine the interaction between alternative medicine and the conventional health care system.

Our final predictions come from Brian Clark, associate director of visual communications, mostly because they’re funny.

1. I will be asked to illustrate no fewer than 15 infographics about behavioral health, which is one of the most difficult topics to illustrate visually.
2. In my best Sean Spicer voice: In 2018 we will have the largest audience to ever witness a Hot Issues in Health conference. Period.
3. I will continue to give complete credence to every scientific study that says people who stay up late, use curse words, procrastinate, love puns, daydream, have messy desks and/or enjoy bourbon possess above-average intelligence.