Obamacare can survive Trump
What will Paul Ryan and the Trump administration do now that they have failed to repeal Obamacare? They’ll try to sabotage it.
After their legislative debacle, they said they would let Obamacare explode on its own, after which, they hope, the Democrats will come crawling to them, pleading for a new plan.
“I’m open to that,” President Trump announced.
But Republicans, who have tried for years to stop the government from expanding health care coverage, will not wait passively for a disaster to happen.
My experience as President Barack Obama’s administrator of the Centers for Medicare and Medicaid Services should serve as a warning. From Day 1, Republicans did what they could to weaken the Affordable Care Act. While we worked to make it easier for eligible people to apply for Medicaid, Republicans favored rules that made enrollment harder. They cut budgets for implementing Obamacare provisions, like modernized data systems.
And they opposed outreach to educate the public. When we sent beneficiaries a brochure about their new options, Mitch McConnell, then the Senate minority leader, called it “propaganda.” Meanwhile, they spread misinformation, claiming, for example, that premiums were soaring everywhere and that doctors were dropping Medicare, when in fact, overall premium increases were historically low and Medicare patients experienced no discernible change in their access to doctors.
Now that the Republicans are in control of both elected branches of government, they are in a position to undermine the Affordable Care Act from within — and then to blame the law, rather than their own sabotage, for its failure.
Congress, the Trump administration and Tom Price, the secretary of health and human services, could do a lot of damage without overturning the law. This has already begun. Early this year, Trump stopped advertising aimed at persuading healthy young people to sign up for coverage — a perfect way to cause the “death spiral” Republicans are so fond of predicting.
Now, they can starve the agencies that have to administer the law, making it hard for them to do their jobs. They can make it riskier for insurance companies to participate and can decrease enforcement of requirements that policies cover a basic set of benefits. The new administrator of Medicare and Medicaid, Seema Verma, favors giving states waivers to avoid some of the law’s provisions, weakening coverage and increasing out-of-pocket costs. Under Obama, my agency carefully reviewed any state-level changes in Medicaid benefits and marketplace policies, but far less diligence is likely now.
They could also stop learning about best practices from different states’ approaches. In Obamacare’s first seven years, some states, like Massachusetts, Arkansas and California, have come up with creative ways to keep premium increases down by encouraging better care and providing incentives for healthy people to sign up. Others, like Arizona, Oklahoma and Tennessee, have been more passive and have seen much higher increases. Significantly, states that expanded Medicaid have, on average, kept premiums down, because many expensive patients were covered by Medicaid instead of having to enter the marketplace’s high-risk pools.
The Affordable Care Act established the Center for Medicare and Medicaid Innovation to support trials of “new models” of care and payment, and it gave the secretary of health and human services the authority to spread those models if they were proved effective. But the Trump administration shows little interest in learning from what works. It has already stopped the expansion of a new way of paying for hip and knee replacement surgery that has been shown to keep costs down and quality up.
In their charge to repeal and replace, Ryan and company talked only about states that have not done well, ignoring the lessons from those that have succeeded. We can expect that erosive messaging to continue.
Fortunately for the millions of Americans who get their health coverage through the Affordable Care Act, the Republicans are probably going to fail. The program is much stronger than they’d like us to believe. It is not in a death spiral and, if left alone, will continue to meet patients’ needs for the foreseeable future.
But it does need improvement. The individual and small-group market — for those who lack employer-sponsored insurance, Medicare or Medicaid — has indeed been vulnerable to “adverse selection,” in which healthy people stay out and sick people stay in, causing some premiums to go up. This is a significant but reparable defect, and some states have already fixed it. California used extensive marketing to encourage healthy young adults to get insurance and worked with health plans to provide generous benefits at fair prices. Federal support could help other states follow suit.
The law’s transparency provisions, intended to help insurers and patients learn more easily where prices are lower and quality is higher, also need better enforcement and more support. We need to reduce the price of access to such data (while strictly protecting patient privacy).
Finally, insurers are nervous. Because they had difficulty estimating their risks under the law, there were provisions that protected them from miscalculations in the first three years. This worked, lowering premiums by as much as 14 percent. That protection has now been phased out, but help is still possible. Alaska set up an innovative state reinsurance fund to cushion insurance companies from extremely high-cost cases, keeping them from having to impose whipsawing premiums on customers.
Unfortunately, it’s unlikely that any of these fixes will happen anytime under Republicans, who have already staked their reputation on the prediction that Obamacare will soon “explode.” It is hard to imagine that they won’t try their best to make that dire prediction a reality.
Will they succeed? Probably not. The law does too much good for too many people for doctrine to override evidence. But the Affordable Care Act’s opponents have been undermining it for years, and we, its defenders, drop our guard at our peril.
They will try to sabotage it, but they can’t destroy it
Donald M. Berwick, a senior fellow at the Institute for Healthcare Improvement, ran the Centers for Medicare and Medicaid Services from July 2010 to December 2011.