President Obama recently warned that if Congress junks the Affordable Care Act, “133 million Americans with pre-existing conditions” will be in jeopardy. That’s a phony figure, for several reasons. The actual number is roughly 500,000.
For starters, half of Americans get their insurance through an employer, according to the Kaiser Family Foundation. Another 34% are on Medicaid or Medicare. For all these people, pre-existing conditions are no barrier to coverage.
Pre-existing conditions mattered before ObamaCare only in the individual market, but even there few were affected. Many of these people with pre-existing conditions managed to get health coverage through the high-risk pools run by 35 states. Those pools covered about 225,000 people in 2011, according to the Kaiser Family Foundation.
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Two Republican senators are working on legislation that would let states decide whether they want to keep Obamacare or move to a different system. Sens. Bill Cassidy of Louisiana and Susan Collins of Maine both hinted on the Senate floor Tuesday about a bill that would preserve Obamacare, but only for states that choose to keep it. Cassidy said the bill would be essentially the same as a bill he introduced in the last Congress called the Patients Freedom Act. It lets states decide if they want to stay in Obamacare if it is working or leave. “The state could go with the alternative, which we will lay out, the state could opt for nothing — no Medicaid expansion and no help for lower-income folks — or the state could opt to stay in Obamacare,” Cassidy said.
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Donald Trump’s pledge to “repeal and replace Obamacare” was one of his biggest crowd pleasers. Moving forward on his broad replacement themes—expanding health savings accounts (HSAs) and state flexibility—could lead to some surprising and intriguing reforms.
During the campaign, Trump supported the familiar Republican themes of tax-free HSAs and allowing families to deduct health insurance premiums in their tax-returns. He pledged that “we must also make sure that no one slips through the cracks simply because they cannot afford [health] insurance.” This opens the door to a serious and conceivably bipartisan discussion about how to replace the complex structure of ACA subsidies and tax breaks.
In addition to redesigning subsidies, another element is an expanded role for states. The familiar Republican call to take the federal money for Medicaid expansion as a block grant and turn it into subsidies for families to buy private coverage has received plenty of the attention. But the broader theme of giving states much greater flexibility could become a different pathway to the goal of affordable and adequate health coverage for all.
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“As Republicans try to repeal the Affordable Care Act, they should be reminded every day that 36,000 people will die yearly as a result.”
— Sen. Bernie Sanders (D-Vt.), in a tweet, Jan. 12, 2017
Sanders has tweeted as a definite fact an estimate that a) assumes Republicans will gut Obamacare without a replacement b) assumes the worst possible impact from that policy and c) assumes that data derived from the Massachusetts experience can be applied across the United States.
Those are three very big assumptions. Take away any one of them, and Sanders’s claim that repeal of the law will cause 36,000 people to die a year falls apart.
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This morning, the Congressional Budget Office released a report arguing that the partial repeal of Obamacare being contemplated by Republicans would wildly increase the number of people without health insurance, in ways that are difficult to understand. Here are four problems with the CBO’s analysis.
1. The CBO’s estimates assume no Obamacare replacement
2. The CBO massively overestimates the impact of Obamacare’s individual mandate
3. The GOP repeal bill is likely to treat Medicaid differently than the CBO does
4. CBO’s 2010 estimates of Obamacare’s coverage expansion were off by more than 10 million
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A spokesman for Donald Trump sought Monday to elaborate on the president-elect’s plans to replace the Affordable Care Act, vowing that the new administration would lower health-care costs by infusing more competition into the marketplace, including by allowing insurers to sell health plans across state lines.
Trump’s goal is “to get insurance for everybody through marketplace solutions, through bringing costs down, through negotiating with pharmaceutical companies, allowing competition over state lines,” Sean Spicer, the incoming White House press secretary, said during an interview on NBC’s “Today” show.
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“What about the 20 million people who got coverage?”
Republicans are naturally concerned. Liberals have weaponized this number to stop repeal of the ACA. But should 20 million people keep a bad law on the books? To answer this question, Congress must ask two different questions.
First, is the number real? In March 2016, the Department of Health and Human Services (HHS) estimated that 20 million uninsured adults gained coverage under the ACA: 17.7 million non-elderly adults (ages 18 to 64) since October 2013, and 2.3 million young adults (ages 19-25) between 2010 and 2013.
The estimates are based on data from the National Health Interview Survey and the Gallup-Healthways Well-Being Index. The estimates are “adjusted to account for changes in general economic conditions (via employment status), geographic location, demographics and other secular trends.” Thus, the 20 million is an estimate, not a rock-solid fact.
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Lawmakers will soon grapple with the fact that sick people are expensive to cover, and someone has to pay. However, we must understand that there is no certain cost to health insurance.
What the general discussion about how to cover people in the future is missing is that Obamacare is so flawed that by itself it is manufacturing plan premium levels that are at least 30% to 40% higher than they need to be.
The Obamacare insurance exchanges cover only about 40% of those that are subsidy eligible, when the longstanding insurance industry underwriting rule calls for 75% of an eligible group to be covered in order to have enough healthy people enrolled to pay the costs of the sick. This critical point that is being missed.
What would happen if the plans were more attractive––if people saw value in them? And, if we had 75% of the eligible group signing up as a result, what impact would that have on current premiums?
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Practically since Obamacare became law, Republicans in Congress have been promising to repeal it. The law has been consistently unpopular during that time as well.
The January edition of the Kaiser Health Tracking Poll shows that those who want to repeal Obamacare outnumber those opposed 48 percent to 47 percent. This is higher than in the November edition, which found that 43 percent wanted to repeal or scale back the law.
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It’s clear that whatever replaces Obamacare must focus on quality and incremental local solutions, not one-size-fits-all government mandates.
In this respect, the federal government’s biggest task for replacing Obamacare is to get out of the way and let state policymakers and health care providers innovate.
First off, let’s get clear what Americans want: They’d like many choices of affordable health insurance plans that allow them to choose their doctors. They want to buy a plan when they are young, then keep their plan from job to job and into retirement. And they’d like it to be truly affordable. These “must haves” are obvious to people of any political orientation.
Instead of approaching this challenge like designing a single system or product (the way Obamacare was constructed), Congress needs to help these conditions develop organically, while preserving freedom of choice for Americans.
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