With Monday's collapse of the Senate Republicans' latest effort to repeal the Affordable Care Act, the GOP and the Trump White House are confronted with the question of what to do next, if anything, on health care. That's a question for Democrats, too.
The ACA was the product of compromise from its inception, and also something of an experiment. No one was sure how all its moving parts would work. The law's drafters and supporters expected that real-world experience would allow them to come back and strengthen the provisions that were working and fix those that weren't. Those expectations were dashed by the GOP's seven-year insistence that revision of the ACA begin and end with repeal.
But there's no dearth of proposals for making the ACA work better. With exquisite timing, Andrew Sprung of Xpostfactoid on Monday afternoon unearthed a package proposed in January by John Holahan and Linda J. Blumberg of the Urban Institute. It's an excellent starting point that attempts to balance improvements to the law with concessions that Republicans might find palatable enough to bring on board.
If Republicans and Democrats could come together in a good-faith effort to improve the Affordable Care Act, what should be on the table? Here's a digest of the suggestions for fixes and concessions offered by Holahan and Blumberg.
The fixes:
Expand the subsidies
As the Urban Institute authors observe, the ACA's premium subsidies are too low, and the income cutoff too sharp, to make coverage truly affordable for many working- and middle-class families. Under current law, subsidies are provided to households earning up to 400 percent of the federal poverty line, or $98,400 for a family of four. They're entitled to enough so that the cost of a benchmark silver-level health plan, which would cover an average 70 percent of medical expenses, won't cost them more than 9.69 percent of their income.
Above 400 percent, however, the subsidies disappear. Holahan and Blumberg calculated in a separate study that households just above the cutoff--those earning 400 percent to 500 percent of the poverty level--took the greatest hit in insurance costs, paying a median 18.1 percent of their income in premiums and out-of-pocket expenses. That accounts for complaints that the ACA increased the cost burdens on the middle class in order to pay for better benefits for lower-income households and explains why the law has struggled to win approval from more than a bare 50 percent of Americans.
Holahan and Blumberg propose lowering the cost cap to 8.5 percent of income and applying it to all households, whatever their earnings. This wouldn't be much of a windfall for higher-income families, they argue, because premiums and out-of-pocket spending don't normally increase with income, so as income rises, the share spent on health coverage falls naturally. They also would peg subsidies to a gold-level plan, which covers an average 80 percent of expenses, rather than silver. Gold plans typically have lower deductibles and co-pays.
Step up education and outreach
States with vigorous public outreach programs, such as California, consistently have experienced higher ACA exchange enrollment than those that neglected them or even interfered. And the Trump administration's cutback of ACA outreach and marketing immediately after the inauguration is widely blamed for a slowdown in ACA exchange enrollments in January and February, relative to the same period in previous years.
Once Republicans capitulate to the reality that the ACA is here to stay, there's no reason not to make sure that the largest share of eligible beneficiaries know to sign up.
Cap payments to doctors and hospitals
Reduced competition among health plans in some regions, a problem under the ACA touted incessantly by the GOP, leads to higher reimbursement rates for medical providers and consequently higher premiums. Holahan and Blumberg have a simple solution drawn from Medicare: cap those reimbursements. It's unlikely that limiting them to Medicare rates or slightly higher would drive providers out of the market; Medicare has little trouble signing up doctors and hospitals to serve their enrollees.
What concessions could Democrats offer to bring Republicans to the table?
Replace the individual mandate
This is by far the most unpopular element of the Affordable Care Act, and the focus of the GOP's pitch that Americans shouldn't be forced to buy anything they don't want. Some means of goading healthier people into buying insurance is obviously a necessary adjunct to the ACA's requirement that every buyer be offered essentially the same price, regardless of medical history, which is a part of the law that Americans widely favor.
Senate and House Republicans proposed replacing the tax penalties imposed on those without insurance with a waiting period for anyone who allowed a lapse in coverage for at least two months. During the wait, the enrollee's pre-existing conditions wouldn't be covered, but that raises the issue of how to protect such buyers from what could be catastrophic costs in the meantime.
Holahan and Blumberg suggest instead a version of the late-enrollment penalties imposed under Medicare Parts B and D. These voluntary parts of Medicare, covering doctor and outpatient visits and prescription drugs, are partially paid by enrollees. Those who wait past their initial eligibility periods to sign up are hit with lifetime premium surcharges.
Holahan and Blumberg propose that ACA penalties be limited--say to one or two years--instead of permanent. The goal is to "make the penalties strong enough to be effective in maximizing enrollment, yet not so punitive" that people wouldn't be able to afford coverage if they're subject to the penalties.
Kill the employer mandate
Even pro-ACA economists acknowledge that it achieves little, especially when balanced against its unpopularity.
Expand Health Savings Accounts
HSAs, which are tax-advantaged accounts that can be used to pay out-of-pocket medical expenses, are a boon to high-income households because they permit yet more sheltering of income from taxes. That's why the GOP has placed them front and center among its Obamacare "replacement" ideas. But despite the GOP's claims that HSAs are good for everyone, for working-class families with limited income tax liability and little disposable income to use to fund the accounts, they're relatively useless.
The Senate and House proposed raising the maximum annual contribution limits for HSAs to $6,550 for individuals and $13,100 for families, up from $3,450 for individuals and $6,750 for families. Here's an idea for the Democrats: Let them. As a substitute for genuine ACA reform, HSAs were a fraud; but as a bargaining chip for real improvements, they have value.
Kill the "Cadillac tax"
Among the ACA provisions that Democrats and Republicans all hate is this tax, which is imposed on high-cost employer-sponsored and multi-employer (union-sponsored) health plans. The law levies a 40 percent tax on health plans valued at more than $10,200 for individual coverage and $27,500 for family coverage and union plans. The tax has been delayed to 2020.
The tax was designed in part to equalize the treatment of employer plans, which are tax-deductible for both employers and workers, and individual plans, which are not. But there are probably justified fears that employers will respond by reducing the coverage they provide. Republicans hate the tax because it hits business; Democrats because it hits unionized workers.
So bury it. Since the tax is projected to bring in about $70 billion over 10 years, that funding will have to be replaced somehow, but that shouldn't be too difficult for Republicans and Democrats working together, should it?
Some elements of the ACA need to be preserved at all costs. They include the law's roster of Essential Health Benefits that all plans must cover, including hospitalization, mental health and substance abuse treatment, maternity care, and prescriptions. The absence of any consensus within the Republican caucus on EHBs undoubtedly contributed to the GOP's repeal failure, since most lawmakers seem to understand that these benefits are the essence of decent health insurance. They should be off the table.
But that leaves a smorgasbord of workable options. Once the GOP divorces itself from an ideological commitment to repealing the ACA, the Democrats may well be inclined to a bit of horse-trading to achieve the improvements that almost everyone agrees are warranted. Let the bargaining begin.
Editorial on 07/23/2017