The Atlanta Journal-Constitution
No easy, cheap fix for ACA’s shortcomings
Remember that Saturday Night Live character who yelled “just fix it”? He had absolutely no idea how to do it; he just wanted it done ASAP. Well, the Affordable Care Act (Obamacare) can’t be easily fixed — or repealed, as the GOP and President Donald Trump have discovered.
Although it is clearly better than nothing, I have never been a big ACA supporter. We still have 30 million Americans without health insurance, a morally unconscionable state of affairs for the dominant nation on Earth.
And, the earlier predictions that I made in letters and op-eds about cost escalation under the ACA due to adverse selection (the young opting out) have all come true. Premiums went up 13 percent this year in Georgia (based on October 2016 Kaiser Family Foundation research on the ACA silver plan), although a few states had increases as high as 145 percent (Arizona). It is important to note that subsidies lessen the pain for 85 percent of marketplace ACA enrollees.
But, failure to cover everyone and cost escalation does not mean we should just repeal the ACA, as the Freedom Caucus suggests — or replace it with something worse like the AHCA, the Ryan/ Price alternative.
Policies based on doing away with the ACA and simply going back to the private marketplace are grounded solely in ideology. GOP supposed solutions such as tax credits and selling insurance across state lines (already legal here) will not get enough people covered.
We are a caring nation. We cannot just kick 24 million people back into the uninsured category, which is what the AHCA would have done per the CBO.
Clearly, outright ACA repeal will not happen politically. So, how can the ACA be reformed to contain costs and improve coverage?
The most obvious step to increase access is to remove cost sharing by the states, as recommended by the Century Foundation. There are currently 19 GOP-dominated states that have not chosen to expand Medicaid. The most common excuse is that expansion is unaffordable.
For the first three years, the feds picked up 100 percent of the cost. Afterwards, the state share gradually increased to 10 percent. Having the feds pick up the remaining 10 percent removes the unaffordability rationale, although it increases total ACA costs. And, expanding waivers eliminates excuses based lack of flexibility.
Other suggestions to improve ACA accessibility include: improving online services; having more navigators (sign-up assistants); and increasing subsidies to beneficiaries. Unfortunately, these alternatives also increase program cost.
What about the flip side of the issue: cost containment? A key reason for ACA plan premium escalation is the fact that younger uninsured individuals will not buy insurance. They are not as sick as older people and believe they do not need coverage. Fines under the ACA are not heavy enough to change their minds and must be increased substantially.
There are many other cost containment proposals, but all decimate the program’s benefits. Many were contained in the AHCA.
Among the suggestions are: establishing low-benefit/low-cost plans (eliminated by the ACA); having higher deductibles; charging younger folks less and older folks a lot more (up to 5 times as much); and sending Medicaid block grants to states. There is resistance to all of these ideas.
I do expect some eventual tinkering around the edges of the ACA program by Congress. However, the bottom line is that there are no simple and easy ways to: a.) cut costs without simultaneously harming enrollees, or b.) improve coverage without increasing government expenditures.
So, in the short term, we really are stuck with the ACA roughly as it is now.
Longer term, when we look at the health care systems of other developed nations, it becomes clear that some form of a single-payer system is the best solution. This fact was stated by both Trump and Obama before each became president.
Universal access is a given, costs are lower and mortality/morbidity rates are better. If Italy has a health care per-capita cost of $3,200 why are we at $9,000?
With our popular, successful Medicare program, it would make sense to just expand it in fiveyear increments until full coverage is achieved and costs controlled by leveraging federal buying power. Of course, making sense technically does not mean anything will be done.
This Congress is heavily influenced both by industry lobbyists and rightwing ideology. Even if the Democrats take the Senate in 2018 or 2020, the tea party elements in the House will prevent Medicare expansion.
The health reform situation will remain that way until we can get a Congress that is not beholden to big pharma and the insurance companies. Only when the Democratic Party returns to its progressive roots and the GOP once again has a few moderates can Medicare for All be obtained.