The steepest challenges facing health care are not the reforms of the Affordable Care Act, but persistent demographic trends that have long unsettled the industry, said experts who worry the real problems will be overlooked in the clamor for a repeal-and-replace policy in the next federal administration.

The U.S. is mired in health care challenges. It’s battling a rapidly aging population and rampant chronic disease amid a physician shortage and an expensive shift in technology.

“The journey (of the ACA) started because ... this is where we are. Stress is on the system, and I think that’s easy for people to forget,” said Fletcher Lance, global health care lead at consulting firm North Highland. “The problems aren’t political.”

Focusing on solutions to the problems at the core of the system far outweighs the political campaign to trash the ACA — described as a "far from perfect" policy, according to policy and industry experts.

The next wave of reform should be designed to help contain costs.

Total health care spending is on track to increase 6 percent each year for the next decade and utilization of the system is up, said Paul Keckley, editor of The Keckley Report.

The costs and usage are unsustainable.

Yet, there’s a moral imperative to provide care to everyone just as there is a responsibility to make the system affordable, said Vic Gatto, CEO and founder of the Jumpstart Foundry. The ACA, he said, tackled the access part of the equation but made little impact on containing costs.

The costs of the system, including the high utilization and pricey prescriptions, are emerging in premiums both in individual plans and those offered by employers.

It's time, Gatto said, to "evolve the ACA into a holistic" policy.

Health: Further, an offshoot of Jumpstart Foundry, is finalizing a blueprint it wants to guide future health care reform discussions over the next year. It was set to publish no matter who emerged as president-elect, but the importance of remaining focused on fixing the system rather than getting mired in political rhetoric is key at this juncture, Gatto said.

Nashville has a lot at stake in the coming health care debate. It's concentration of expertise can also play a pivotal role.

“We believe we have to do both simultaneously and if (Donald) Trump can work with Paul Ryan and others, (Rep.) Jim Cooper, for instance, to get lots of conversations, then we think Nashville and Health:Further can solve this for all people — as sort of a human right, but be more effective in delivering that care,” Gatto said.

The stocks of Community Health Systems, HCA and LifePoint Health haven’t rebounded from the dip they took the day after the election. The price reflects the uncertainty of how reform will impact access to coverage, and ultimately how providers are paid.

President-elect Trump told the Wall Street Journal in an interview on Nov. 11 that he is open to keeping parts of the ACA, including the ban on allowing insurers to deny plans to those with preexisting conditions and the ability for people to stay on their parents' plan until age 26.

Many of the public exchanges have struggled to find equilibrium and insurers hiked premiums to cover costs. The exit by Blues plans across the country is a telling sign of the actuarial miscalculations, said Ceci Connolly, CEO and president of the Alliance of Community Health Plans.

But the access to coverage was a step in the right direction, particularly in a system that is moving toward rewarding providers for wellness and outcomes, experts agreed.

“It’s pretty simple: rip-and-replace is a mistake," Lance said. "Hopefully that’s hyperbole.”

One of the biggest challenges facing Nashville is keeping the channel of innovation open.

The city is on the cusp of emerging as a health care IT powerhouse with many of the tech developments geared toward a system in which greater reward and emphasis is focused on value.

A slip back into the world of fee-for-service, where providers get paid for individual services rather than outcomes and efficiency, could reverse progress that has brought insurers and providers on board with new payment structures.

Health care is not the same industry it was prior to 2010, in large part because of the rapid adoption of technology and changes in the structure of insurance plans.

According to A.J. Rice, analyst at UBS, the Centers of Medicare and Medicaid Innovation could be closed, as it was disliked by Republicans in Washington, D.C. The center is the driver behind the move toward getting more value-based payments into Medicare.

Such a move would be a blow to efficiency and value in Medicare, the country's insurance net for people aged 65 and older, as well as broader initiatives on innovation, Lance said.

Free market principles, such as transparency was a talking point for Trump during the campaign, which could help lift the veil on pricing — long an obstacle to making the industry more consumer-friendly. Focusing on price “could benefit consumers by giving them the tools they need to shop around for their care,” according to PWC's Health Research Institute report.

“We think innovation and new approaches to solving problems is sort of a core way to thread this needle. If people will come to the table with this moral imperative of ‘let’s fix this’ then it’s a great opportunity for President Trump and Congress,” Gatto said. “I don’t believe there is anyone in Washington who knows how to fix healthcare.”

Reach Holly Fletcher at 615-259-8287 or on Twitter @hollyfletcher.

Read more: Investors bet big on Nashville's young health care firms

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