A BIPARTISAN PATH ON HEALTH CARE
Trump and the GOP could help improve and strengthen the law. But will they?
The failure of Trumpcare can be seen as a rejection of policies that Americans judged would move the country backwards. But it also presents the opportunity to end the divisiveness that hampered the Obamacare era and move forward in a bipartisan direction that focuses squarely on reducing premiums and expanding access.
The policies and the politics of Trumpcare were extreme and favored by only 17% of voters as compared with the Affordable Care Act (ACA), which enjoys support from about 50%. The bill cut care for the neediest children, elderly and disabled to pay for a large tax cut for the wealthy. The process, likewise, began with the most partisan approach possible. Republicans skirted Democratic input, avoided public hearings, and ended up rushing a bill without enough impartial evaluation.
The president has a chance now to turn this around. Last week, he invited Ezekiel Emanuel, a Democratic policy expert who helped craft the ACA, to the White House. The president had already chosen a partisan path, but by inviting Emanuel, he might have signaled a potential interest in a bipartisan approach should that one fail. ‘THE LAW OF THE LAND’ The administration has an immediate opportunity to help Americans by choosing to enforce and properly steward what House Speaker Paul Ryan rightly called the “law of the land.” Two simple decisions could lower the cost of insurance by 25% to 30%, according to a conversation I had with Mario Molina, CEO of Molina Health, one of the largest insurers in the ACA marketplace.
First, the administration and Congress should commit to permanently funding payments that reduce the size of deductibles for lower-income Americans (called cost-sharing reductions). Republicans need to drop a lawsuit they filed to stop these payments, or Trump needs to say they are going to continue.
Second, the administration should enforce the individual insurance mandate until a different approach can be agreed upon.
Those two actions need to be done now before insurers submit initial premiums for next year, or inaction will drive up premiums.
A third step would be to grant states the flexibility to increase competition and reduce costs. Non-partisan analysts such as Standard & Poor’s confirm that the online exchanges selling ACA insurance policies are stable, but in some states insurance is out of reach for those who earn too much to receive tax credits.
The administration has tools to do this, including a section of the ACA that lets states pursue different approaches so long as they meet the basic aims of highquality coverage for more people. Alaska, the first to use this process, last year created a statewide reinsurance pool. Such pools protect insurers against losses in high-cost cases, and the savings are passed to consumers. In Alaska, the result was a dramatic reduction in premiums.
Many red or purple states, such as Kansas and North Carolina, have expressed recent interest in expanding Medicaid to low-income adults. This would not only cover more people, it also would reduce premiums for private policies. Premiums are 7% lower in states that have expanded Medicaid, due to lower-income people (who tend to have more health problems) leaving the exchanges.
FATE UP TO GOP While members of Congress might be wary of taking up another major health care bill, they could try to add bipartisan ACA changes to a bill important to Trump and both parties. One possibility is an infrastructure package.
In recognition that bigger solutions will take time, the president and Democratic leaders should create a bipartisan commission with experts from Congress and the real world, charged with exploring smart ways to reduce health care costs that could result in bipartisan legislation.
The president has pledged to bring down drug costs and should also push forward with initiatives to bundle payments (charge patients for a set of services related to a health episode rather than separately for every test, pill, bandage and procedure) and to pay for what works. Common ground can be found here and, Emanuel told me, was the focus of his talk with the president.
The fate of the exchanges in 2018 is up to Republicans. The ACA has provided a foundation that allows millions of Americans access to care. The focus should now turn toward what the country expects — both parties working together to improve it.