Our nation’s leaders need to synchronize their watches; while President Trump has stated that an Affordable Care Act (ACA) replacement is still a year out, some Republicans in Congress are still promising to repeal the law within two months. To sift through the policy debate at the root of this political theater, health care experts came together at two D.C. events to discuss the state of health reform in the U.S., and the possible paths toward repealing, replacing, or repairing the ACA.
The first panel, hosted by the Kaiser Family Foundation (KFF) and the Committee for a Responsible Federal Budget (CRFB), debated the merits and drawbacks of the ACA as well as alternative policies on the table for a replacement bill. The second, an Alliance for Health Reform (AHR) webinar, dealt with the “nuts and bolts” of health insurance markets during this time of uncertainty.
Here are some key takeaways from the two events:
To Repeal or Not?
At the heart of these policy discussions was the question of whether or not to repeal the ACA. While the health policy wonks spanned the political spectrum, speakers and panelists generally agreed that the law has reduced the uninsured rate, and that market stability, affordable premiums, and consumer choice remain areas of concern. Still, there was disagreement over whether the best course of action is to “repeal” or “repair” the ACA.
Larry Levitt, senior vice president of KFF, articulated the deep roots of the partisan split: while liberals generally strive to increase coverage and access to health care, and accept the cost, conservatives are often more concerned with cutting costs and regulations. Panelists who argued for repeal employed rhetoric to that effect; Joseph Antos from the American Enterprise Institute asked bluntly, “How much money do you want to take out of your pocket to give to somebody you don’t know for some kind of service that you’re not too sure about?” Other panelists echoed this sentiment, calling for “personal responsibility” through Medicaid reform and public health initiatives. Avik Roy, who authored an ACA replacement blueprint, argued that we don’t need big government to ensure that everyone has a smart phone, and we shouldn’t treat health care any differently.
On the other side, progressive policy experts argued that repealing the ACA would be shortsighted. Harold Pollack from the Century Foundation stated that the passage of the ACA symbolizes “our basic commitment to protect each other against catastrophic things,” noting that “the poorest people in America” now have access to care. Linda Blumberg from the Urban Institute explained what the individual market looked like prior to the ACA, highlighting the vast transformation to the health care system that now provides more benefits with less price variation. Chris Jennings of Jennings Policy Strategies also noted that before the ACA, the business model for insurance companies was “to avoid sick people,” and the ACA was the result of “insurers, consumers, and the country” working towards a new, more equitable system.
Whether or not they wanted to repeal the ACA, across the board, panelists and speakers advocated for change. Stephanie Carleton from McKinsey & Company lamented that, for many middle-class Americans, premiums are half of a mortgage payment. Brian Webb of the National Association of Insurance Commissioners voiced state concerns, urging more consistency in federal regulations and increased state flexibility. Liz Fowler, who played a major part in drafting the ACA, offered that there was bipartisan agreement in what needs to change, but called for an end to catastrophic rhetoric surrounding the law. “Are we there yet?” she posited, “Not quite, but let’s not tear down everything.”
An ACA Alternative
Panelists also considered how to replace the ACA, should it be repealed. Bill Hoagland from the Bipartisan Policy Center acknowledged that “the proverbial dog has caught the car, and now what does the dog do with the car?” After praising the Cassidy-Collins compromise allowing states to keep ACA reforms for it’s emphasis on state flexibility, Hoagland mentioned Rand Paul’s plan, and asserted that Health Savings Accounts (HSAs) would be part of whatever Republican replacement plan comes to the forefront.
Some experts maintained that we haven’t yet seen the actual replacement bill, speculating that the collection of proposals would eventually coalesce and include some standard Republican health policies. Antos promoted stabilizing the risk pool by encouraging healthy people to enroll, perhaps through a continuous coverage provision, a point reiterated by Chris Holt of the American Action Forum during his presentation. Age bands and essential health benefits were cited by many critics of the ACA as driving up prices for young and healthy people, leading to a less-healthy risk pool; they called for fewer regulations on insurance companies, such as Roy’s idea to move maternity coverage from a mandatory benefit to a separate rider, reducing costs for men and women who aren’t of childbearing age.
Other Republican proposals drew sharp criticism, even from proponents of a repeal strategy. Interstate sale of insurance, for example, was condemned by Holt, who warned of a potential regulatory race to the bottom. Antos, who has previously called for high risk pools, noted that they would need to be funded at a higher level than in the past, with an option to “graduate” back to the commercial market. ACA advocates chimed in, including Peter Lee, Director of the ACA’s first state-based exchange, Covered California, who warned against regressive financial assistance proposals like a flat subsidy without any income adjustment. Jennings, responding to calls for state flexibility in Medicaid, asserted that Republican proposals to increase state flexibility include major cuts to federal funding.
Since the election in November, health wonks have been busy. The ACA fundamentally changed our health care system, putting consumers first in a business that, as Jennings noted, profited by discriminating against sick people. As the stack of replacement bills gets higher and political pressure mounts, policy experts play a critical role in shedding light on past problems and projecting the future impact of proposals that will touch millions of people.