Normative Narratives

How to Compromise and Fix the ACA

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Time to Replace Those Repeal Attempts

The Senate’s latest attempts to repeal and replace the Affordable Care Act (ACA) have all failed to pass.

The most comprehensive attempt, the Better Care Reconciliation Act, was voted down 43-57. Defections came from both sides of the GOP–some thought the bill was too hard on low and middle income people, while others thought it left too much of the ACA in place.

With repeal and replace off the table, President Trump changed his tune from “repeal and replace” to “repeal, then [try to] replace”. The Congressional Budget Office (CBO) forecast that “a plan to repeal Obamacare without replacing it could cost 32 million Americans their health insurance by 2026…at the same time, premiums on individual insurance plans would rise 25 percent next year and double by 2026 if Obamacare is repealed.” This effort also failed to gain enough support in the Senate, as it was defeated 45-55.

These CBO projections and Senate votes reflect the fact that people do not want to go back to the pre-ACA days when they could be denied coverage due to pre-existing conditions. As the reality of the modern economy pushes back the typical age of financial independence, the ACA provision allowing young adults to stay on their parents health insurance until 26 has bipartisan support. Minimum standards ensure people who pay for coverage are actually covered when it is time to receive treatment. The individual mandate, while unpopular, ensures a reasonably healthy risk pool for insurers.

All this is to say that the ACA, while imperfect, was designed the way it was for a reason. “A la carte ACA” or the “skinny repeal” would not work, particularly without the individual mandate. Sicker risk pools would lead to a “death spiral“, driving up premiums for middle class customers and subsidy costs for the Government, all while increasing the number of uninsured. For those still keeping score at home, the CBO estimated the “skinny repeal” would result in 16 million Americans losing health insurance over a decade and raise insurance premiums by 20 percent in January. Thankfully, the “skinny repeal” also failed in the Senate, 49-51.

[In other news, the GOP wants to gut the CBO–talk about shooting the messenger]

With so many failed repeal efforts, it is clearly time to try to work towards improving the ACA. Many of the ACAs problems are the result of a lack of competition (see the map above)–private insurers are simply not participating in certain markets, particularly in rural areas (a problem that is expected to get worse in 2018).

The solution to this market failure is to create competition by allowing people to buy into the Medicaid “Public Option”.

I can already hear the outrage from Conservatives–“of course a liberal’s answer is more government”–but hear me out. The Public Option need not increase government spending drastically; people would receive healthcare at cost, but they would still pay–this is not a Medicaid for all as an entitlement proposal. Sure, administrative costs for the government would rise as the program absorbed more people, but the marginal cost of providing care for people who are currently ineligible for Medicaid should be close to zero (some scaling would be needed to smooth costs for people just above Medicaid thresholds).

Furthermore, with the Public Option in place, Medicaid would be in even better position to negotiate lower drug prices with pharmaceutical companies, a cost-saving idea championed by many, including President Trump.

Of course, in order to garner support for a Medicaid Public Option, concessions must be made to conservatives.

Removing the employer mandate:

With a reliable, affordable option that covered all essential health benefits, people would have a much clearer economic decision to make–accept a job that pays less but offers insurance, or take a job that pays more knowing they have to set aside a certain amount for insurance. The Public Option would make buying health insurance a predictable financial choice for the first time in American history.

This concession tackles a major criticism of the ACA–small businesses would no longer be required to factor in the cost of providing health insurance when deciding whether or not to hire more employees.

A higher employee threshold could also be kept in place to ensure larger corporations offer a health insurance option to their employees

Reviving Ted Cruz’s Essential Benefits Plan:

For those not familiar with it, Ted Cruz proposed a plan in which health insurers would be able to offer non-ACA complaint plans–ones that do not cover all essential health benefits–as long as they offer a plan that does cover them as well.

Clearly marking which plans do and do not cover all essential health benefits would be important, but it would also be easy enough. The real issue with Cruz’s plan was there was no way to ensure the ACA-compliant plan was being offered at a reasonable rate, and not just as a token to unlock the right to sell non-compliant plans. 

But with the Public Option, it wouldn’t really matter; if the ACA plan was offered at an unaffordable rate, people would have the choice to opt-in to the Public Option. 

This concession tackles another major criticism of the ACA–people would no longer have to buy insurance covering care they don’t feel they need.

President Trump said “Obamacare is Death”, while Senate majority leader McConnell called it a “nightmare”–empty hyperbole meant to scare people who do not know better. In the darkest of ironies, their very replacement ideas would have truly be a living nightmare for millions, and would have lead to many preventable deaths.

In defeat, President Trump tweeted (of course he did) to just let Obamacare fail. There is much his administration can still do to undermine the laws effectiveness if it truly prioritizes political vendettas over the well-being of American citizens. The GOP has (thankfully) proven it can still be the party of “No” when it comes to Healthcare, even when it is the majority party. Now is the time to see if it can be the party of “Yes” for a stronger, bipartisan plan, the American people want and deserve.

Update (8/24)

Every U.S. county is expected to have an insurer in the 2018 Obamacare marketplaces. However, having one insurer does not mean there is competition or choice. 1,478 counties could have only one insurer in 2018, potentially leaving customers without an affordable option.

Expect more updates as 2018 plans are finalized in the coming weeks.

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