The November election has thrown open the door to changes to health care coverage, both in the private market and in Medicaid. In the last four years, millions of Americans have been able to obtain health coverage for the first time, but as demonstrated by enrollee surveys, many people don’t like the high premiums, high out-of-pocket costs and narrow provider networks in currently available plans. According to the Colorado Health Access Survey, more than four of five uninsured Coloradans say that insurance costs too much.
However, a post-election survey also shows that a significant majority of Americans likes certain aspects of what they’re getting now through the Affordable Care Act (ACA). Regardless of party affiliation and candidate preference, they support the ability to get free preventive care with their health plan (at least 75% ), the ability to keep their kids on their plans until age 26 (at least 83%), the availability of financial help such as premium tax credits and cost-sharing reductions to purchase and use their coverage (at least 68%), access to coverage regardless of a person’s medical history (at least 63%), and the Medicare payroll tax increase for upper-income Americans (at least 62%) which helps keeps Medicare solvent.
It would seem obvious that any “replacement plan” for the ACA should meet the public calls for more affordability and access while maintaining key protections. Unfortunately, to date, no replacement is in the offing. Instead, it appears the first option on the table is a backdoor repeal of the ACA through the mechanism of budget reconciliation. Through that procedural maneuver, the Senate would strip funding from the ACA and start the unraveling of the current health care system.
The funding that in 2017 will give eligible Coloradans an average insurance subsidy of $358 per month and lets many pay less for coverage than they did in 2016 would disappear, along with the federal funds that make it possible for thousands of working Coloradans to get health care through the Medicaid expansion. With funding and mandates gone, many will exit the exchanges and individual market, leaving behind sicker and wealthier customers, and driving premiums even higher.
The clear limitation of that backdoor budgetary maneuver is that it is specific to budget items and can’t be used to put a better health care law in place. It’s as if Congress heard that you didn’t like the only grocery store in town and scheduled a date to demolish it – without a replacement plan. You and your neighbors will likely go hungry while Congress vets the options, get permits, designs and builds a new store, hires staff and stocks it with food. (Meanwhile, the few folks in town who can afford to will fly in all their meals and do fine).
Tom Price, newly nominated to lead the Department of Health and Human Services (HHS), has given general indications of how he envisions our future health care system, but his proposals would help the wealthy, not middle- and lower-wage earners. As an example, expanding access to Health Savings Accounts (HSAs), favored by Paul Ryan and Tom Price, only help consumers if they have the luxury of setting cash aside each month. Indeed, many Americans simply lack the income for such savings. In fact, only a third of Americans with incomes under $40,000 could come up with enough cash to pay for even one $400 emergency expense. Only half of Americans saved any money in 2015. In contrast, a majority of those who have made HSA-deductible contributions report incomes over $100,000, and they reap major benefits: the money deposited into an HSA reduces taxable income, interest on the account accumulates tax-free, and no tax is paid when the money is used on medical expenses. With HSAs, more money will flow to those who already have it.
Another possibility is the re-establishment of high-risk pools, though Coloradans familiar with Colorado’s pre-ACA state high risk pool, Cover Colorado, are familiar with its many deficits — including high costs to consumers, six-month exclusion periods for those with pre-existing conditions, a lifetime maximum benefit that cuts off those with greatest need and significant net program losses. As a rule, such programs have not been sustainable over time.
Evidence suggests that yet another potential change, giving carriers the right to sell plans across state lines, also wouldn’t provide Coloradans with more affordable coverage. Because carriers could base plans outside of Colorado, Colorado regulators would be unable to enforce state-legislated consumer protections. The National Association of Insurance Commissioners (NAIC) predicted that such a change would reduce availability of insurance. And the conservative Heritage Foundation expressed doubts that the approach would reduce prices.
No backdoor repeal – no defunding through budget reconciliation – should take place unless Congress can show the American people a plan that keeps what people like about the ACA and our health care system, while working on efforts to improve coverage and make it more affordable. Coloradans want better, more affordable coverage, not less access to care.
You can make sure your views are heard by letting your Senators and Gov. Hickenlooper know that you want to hear about the new plan first, before anything is taken away through a backdoor repeal.
– Bethany Pray