Texas ACA ruling imperils innovative Md. health care model

President Trump moved Thursday to scale back rules on health insurance across the country in the administration’s most ambitious effort to date to use its regulatory powers to undermine the Affordable Care Act.

A Texas judge’s decision to invalidate the Affordable Care Act just hours before open enrollment for 2019 was set to close, was enraging. Much has already been written about the effects on the individual mandate, people losing coverage and how to maintain protections for those with pre-existing conditions. These are crucial issues, and we urge the General Assembly to consider legislation that would address some of them that are not currently codified in Maryland law.

One potential implication that hasn’t seen much coverage yet is for the future of Maryland’s total cost of care model of health care. Let me explain.


In 2013, Maryland negotiated approval of a new five-year all-payer model of care with the federal Centers for Medicare and Medicaid Services (CMS). This model established global budgets, which provided hospitals with a fixed amount of revenue for the upcoming year and encouraged hospitals to improve outcomes for patients, such as working to eliminate unnecessary hospitalizations. The model was a resounding success, achieving significant savings for Medicare and with the promise of improving care for patients.

This July, a new agreement was reached with CMS to establish a total cost of care (TCOC) model in Maryland — the first of its kind in the country. Under this model, which officially launches in January, Maryland will build on the success of the all-payer model and create greater incentives for providers to coordinate patients’ care. TCOC sets a per capita limit on Medicare total cost of care, which is projected to save Medicare over $1 billion by the end of 2023. It also sets up a new statewide Primary Care Program to offer and incentivize more coordinated care to patients.

What does all this have to do with the recent court decision? The TCOC model was negotiated with a division of CMS called the Innovation Center, which was formed under the ACA to support states’ development and testing of innovative health care payment and service delivery models. Without the ACA, the future of the Innovation Center, and therefore the programs it is designed to foster, is in doubt. The contract that CMS and Maryland signed to establish the TCOC and the Primary Care Program should be secure, but what about the goals of the TCOC as a whole? Without the ACA, how will Maryland continue to innovate to improve patient experiences, improve population health and reduce the total cost of care?

We don’t know the answers to these questions yet. We do know that Maryland must continue to pursue the essential goals of the ACA by ensuring that all Marylanders have comprehensive and affordable health care and by retaining the cost-free preventive services provided to the Medicare population that is the first target of the TCOC.

The Affordable Care Act touches every aspect of our health care system. It is responsible for enormous gains in coverage, particularly among populations that were previously excluded from Medicaid and shut out of the private marketplace. It has enabled Maryland and other states to pursue innovations in care and better outcomes for consumers. It makes no sense to deconstruct the ACA, especially at a time when Maryland is making significant strides to support stronger care coordination and better outcomes for its seniors while working to address the goal of improving overall population health.

Congress needs to do its duty and ensure quality health coverage for everyone, whether this ruling stands or not. However, it is clear that Maryland cannot rely on the federal government or the courts to safeguard our citizens’ health care. We appreciate the steps taken by Maryland's attorney general and urge our lawmakers to pass common sense, bipartisan legislation in the upcoming General Assembly session to ensure our state maintains its unique care model and explores innovative solutions to provide quality, affordable health care to all Marylanders.

Leni Preston ( is vice president of Consumer Health First.