Shoring up the ACA on the Road to Universal Healthcare

While interest in expanding Medicare to all people has grown substantially, the road to universal healthcare in this country remains long and arduous.  We need to defend, protect, shore up and improve the Affordable Care Act (AKA Obamacare) in the meantime.  Here’s why:

The ACA was the first major step toward health reform since Medicare and Medicaid were established in the 1960s. Through marketplace insurance “exchanges” for individuals and an expansion of Medicaid eligibility, it made healthcare accessible to millions of people who had no workplace insurance and were not eligible for Medicare or traditional Medicaid. It provided many low-income people with subsidies for their premiums on the exchanges. In the process of enrolling with the help of “navigators,” many people learned that they were eligible for Medicaid and enrolled in that program. 

To ensure a balance of healthy and sick people among the insured population (the principal way to keep costs down), the ACA created an “individual mandate” to have health insurance that met ACA requirements for non-discriminatory, comprehensive coverage with defined “essential benefits.” At tax time, people who could afford health insurance but had not enrolled were to pay a modest penalty that would grow over time. (Under Trump, this rule was not enforced, reducing its effectiveness.)

The ACA ended the most egregious practices of the health insurance industry,  resulting in a new business model for selling coverage to anyone who applies, regardless of pre-existing conditions, gender, or age.  All qualifying insurance policies cover essential health benefits: from preventive care and chronic disease management; hospitalization and emergency services; maternity, newborn and pediatric care; rehabilitative care; and prescription drugs to mental health and substance abuse treatment (which affects millions of people with opioid addiction). 

The ACA unleashed a tidal wave of innovation in the delivery of health care, focusing on prevention of sickness and enhanced doctor-patient relationships.By reducing the infamous “donut hole” in prescription drug coverage for Medicare beneficiaries, it saved seniors more than $20 billion on their medicines. The ACA also expanded a drug discount program to more hospitals, many in rural areas.

Since the ACA was signed into law by President Obama in 2010, it has become embedded in the nation’s healthcare system. More than 20 million Americans have obtained health insurance with its help.Despite facing politically motivated opposition, the ACA has high approval ratings today. 

The main problem of healthcare affordability todayis not caused by the ACA,but by an Administration and Congress that has done its utmost to repeal or at least undermine and blatantly cut critical elements of the healthcare reform. Early on, the Supreme Court killed the ACA requirement that allstates expand their Medicaid programs (with the help of considerable Federal dollars).  States that chose to expand Medicaid, especially early on, did well, providing healthcare to millions of low-income people who did not qualify for traditional Medicaid and could not afford the least-expensive policies on the individual exchanges. 

Then Trump was elected and, one by one, many of the critical components of the ACA have been threatened or boldly cut.  

Failing to “repeal and replace” the ACA in 2017, Congress attacked it through the “2019 Tax Code”signed into law that December. Ostensibly to pay for enormous, permanent corporate tax cuts, Congress reduced tax credits for premiums as well as healthcare subsidies for low-to-moderate-income people, leaving many middle class families with unaffordable insurance premiums. (People with much lower incomes fared better.) The new tax code also repealed the individual mandate, a key ACA component to reduce costs. The Congressional Budget Office (CBO) projected that these cuts would lead to 13 million more people losing their healthcare by 2027 and would drive up premium costs by an additional 10 percent each year for families purchasing their insurance on the individual market

What he could not get from Congress, Trump succeeded through executive orders. Just a few examples include shortening the open enrollment period for the exchanges, drastically cutting funds for enrollment assistance and advertising, and ending cost-sharing subsidies to insurers to protect those who had an abundance of sick people.

These sabotage efforts—especially the “on again-off again” decrees to eliminate protections for the 1 in 4 Americans with preexisting conditions—createuncertainty in the market and undermine the healthcare system. Uncertainty results in less competition in the marketplace and higher prices for health consumers. It also creates fear among people:  even if they can afford healthcare now, as out-of-pocket costs continue to rise, they or someone in their family could become seriously ill or have an accident that would make them paupers, or they simply could not afford to treat the illness or accident. (In the pre-ACA days, thousands of people became bankrupt from high medical bills, or died as a result of no treatment.)

So far, Trump’s idea of “great insurance” has been to allow states to offer cheap insurance plans that do not comply with the ACA’s consumer protection requirements and essential benefits. Typically bought by young and healthy people, these plans compete with those on the exchanges. Recently Jessica Altman, Pennsylvania’s Insurance Commissioner, testified before the U.S. House Energy and Commerce Committee’s Subcommittee on Health on the harm that these limited, deceptive plans cause for consumers and the health insurance market.

With Congress having failed to “repeal and replace” the ACA, and emboldened by the end of the Mueller investigation, Trump is now trying for a total repeal of the ACA through the courts. A Texas court case advocating total repeal (which the Administration conveniently ignored) has moved on to a federal appeals court that may hear the case in July. California’s Xavier Becerra is leading a coalition of other Blue State attorney generals to block the repeal effort, which would have a devastating impact on millions of Americans. A total repeal would result in loss of insurance for many people with pre-existing conditions and the end of Medicare Expansions in most states. Many people with opioid addiction or mental health problems would lose treatment coverage. Rural hospitals and other treatment centers that depend heavily on government support for Medicaid patients would be hard hit. Already hospitals in poorer states are closing due to funding cutbacks, and many more would be forced to close. Even insurance companies are nervous about prospects of a total ACA repeal as they start filing rate requests for next year. For them, the ACA’s loss of the penalty for going without health coverage—the individual mandate—was bad enough.

Our Senator Casey, a champion of the ACA, is among the senators leading the charge to protect it and all Americans by restoring cuts, as well as finding other commonplace solutions to make healthcare more affordable. Pharmaceutical prices are low-lying fruit, and Casey is working on legislation to allow importation of drugs from Canada. He also supports creating a Medicare-like “Public Option” to compete with private insurance, giving consumers more choices.  

Casey and other Senate Democrats are still hampered by a Senate Majority that is eager to move away from healthcare reform. Perhaps the Court case that threatens to repeal the entire ACA will motivate Republicans at least to preserve protections for people with pre-existing conditions. Most of these Senators learned in the mid-term elections that it would be political suicide for them not to do so.  

Much remains to be done to make healthcare more affordable. The only hope is to elect to Congress more people who want to do it. On May 21st, there’s a special election to fill Senator Alloway’s position. Independents, this is your chance to vote during a primary! I encourage everyoneto vote—but vote wisely, knowing the positions candidates will be taking on healthcare and other issues important to you.

 

Jeanne Duffy, Ph.D., has served as a college professor, an analyst and project manager for several large companies, and a college administrator in charge of foundation and government support. She is an active member of Gettysburg Democracy for America’s healthcare taskforce.