Say, did you notice how the eleven governors calling for bipartisan health care reform referred to the Senate’s attacks on the Affordable Care Act by putting “repeal” in quotation marks? That subtle punctuation may refer to what has Senator Rand Paul so cranky: from the first House bill on, the GOP proposals to “repeal” the Affordable Care Act have actually left most of the ACA in place:

Enacted seven years ago this month, the Affordable Care Act includes ten separate titles (similar to chapters in a book), each addressing a distinct subject matter.  Four of the ACA’s titles involve Medicaid and commercial health insurance market reforms.  These provisions comprise what is now commonly referred to as “ObamaCare.”

The ACA’s remaining six titles, which total 525 pages, address healthcare payment and delivery system reforms.  It is here you will find the legislative mandates for the Medicare value-based purchasing programs (e.g., Hospital Readmission Reduction Program, Medicare Shared Savings Program), as well as funding for the Center for Medicare and Medicaid Innovation (CMMI).

The American Health Care Act deals almost exclusively with ObamaCare.    With one exception, the bill does not repeal any provision in the ACA’s six titles addressing payment and delivery system reforms.  The exception is Section 4002, which appropriates $2 billion each year to fund prevention and public health initiatives; that funding would end in 2018 under the proposed legislation.  Other ACA appropriations, including funding for CMMI, remain untouched [Martie Ross, “The American Health Care Act: What’s Not There, and Why It Matters,” PYA Healthcare Blog, 2017.03.09].

The original GOP “repeal” plan left 524 of the ACA’s 974 pages untouched. That’s 53.8%. Each iteration of the GOP repeal effort has left in place more of the ACA. The Republican Congress is thus acknowledging that the bulk of the Affordable Care Act is good policy.

Among the Affordable Care Act’s successes is the Hospital Readmissions Reduction Program, a key part of the health care reforms President Barack Obama said we needed in 2009 to save money for Medicare:

Second, we need to use Medicare reimbursements to reduce preventable hospital readmissions. Right now, almost 20 percent of Medicare patients discharged from hospitals are readmitted within a month, often because they’re not getting the comprehensive care that they need. This puts people at risk; it drives up cost. By changing how Medicare reimburses hospitals, we can discourage them from acting in a way that boosts profits but drives up costs for everyone else. That will save us $25 billion over the next decade [President Barack Obama, address to American Medical Association, 2009.06.15].

The ACA-HRRP created penalties to encourage hospitals to send Medicare patients home in better shape with better guidance to keep from having to come back to the hospital:

The HRRP was established by a provision in the Affordable Care Act (ACA) requiring Medicare to reduce payments to hospitals with relatively high readmission rates for patients in traditional Medicare. Starting in 2013 as a permanent component of Medicare’s inpatient hospital payment system (i.e., not a temporary demonstration project), the HRRP applies to most acute care hospitals. Exempt hospitals include psychiatric, rehabilitation, long term care, children’s, cancer, and critical access hospitals, as well as all hospitals in Maryland.⁴

Under the HRRP, hospitals with readmission rates that exceed the national average are penalized by a reduction in payments across all of their Medicare admissions—not just those which resulted in readmissions. Before comparing a hospital’s readmission rate to the national average, CMS adjusts for certain demographic characteristics of both the patients being readmitted and each hospital’s patient population (such as age and illness severity). After these adjustments, CMS calculates a rate of “excess” readmissions, which links directly to the hospital’s readmission penalty—the greater each hospital’s rate of excess readmissions, the higher its penalty. Each year, CMS releases each hospital’s penalty for the upcoming year in the Federal Register and posts this information on its Medicare website [Cristina Boccuti and Giselle Casillas, “Aiming for Fewer Hospital U-Turns: The Medicare Hospital Readmission Reduction Program,” Kaiser Family Foundation, 2017.03.10].

HRRP has worked:

A new analysis led by Harvard researchers published in Tuesday’s Annals of Internal Medicine shows the program reduced readmissions rates for “myocardial infarction, heart failure and pneumonia decreased more rapidly than before the law’s passage.” And a separate analysis from doctors at Yale School of Medicine found hospitals that were penalized were more likely to reduce readmissions for all conditions, researchers said [Bruce Japsen, “How Obamacare’s Hospital Penalties Save Medicare—and Lives,” Forbes contributors, 2016.12.28].

This Bloomberg article further supports the fact that HRRP is doing what it was designed to do. But if the ACA is pushing hospitals to keep patients from coming back, might that not result in hospitals not readmitting patients who need care, just to keep their readmission rates low, and thus put patients’s lives at risk? No, not according to a new JAMA article published yesterday:

After studying more than 6 million hospitalizations from over 5,000 hospitals over a seven-year period, we found no evidence that the reduction in hospital readmissions resulted in greater risk of dying for patients recently discharged.

In fact, hospitals that reduced readmissions the most were, if anything, more likely to reduce mortality after hospitalization. These findings held even for patients with heart failure, who had rising mortality over time as the least sick patients were increasingly treated as outpatients.

How did this happen? To lower readmissions, hospitals needed to better prepare patients and families for discharge and improve the integration and coordination of care from hospital to home. These interventions likely also reduced the risk of death.

Amid the noise of the health care debate, it is useful to reflect on a success such as this [Kumar Dharmarajan and Harlan M. Krumholz, “Pushing Hospitals to Reduce Readmissions Hasn’t Increased Deaths,” NPR: Shots, 2017.07.18].

The Hospital Readmission Reduction Program is Obamacare saving money and saving lives. That’s why Republicans who voted for clean ACA repeal under veto-certain Obama won’t vote for it under reckless Trump: they can’t really justify getting rid of a program that works.