James C. Capretta argues that going forward, the goal shouldn’t be to find a bill that is acceptable to 100% of the Republican caucus. Even if that were possible, it would entail too much risk of another political debacle. On health care, he says that Republicans will be better off trying to reach a deal with some willing Democrats. That can be done, but only if Republicans first demonstrate they are serious about producing a workable approach that moves decisively away from key ACA provisions without leaving millions without insurance. If they do that, and the CBO produces an estimate showing it would work, they will find they have the leverage necessary to bring some willing Democrats to the table and get a good deal.
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It is premature to assume health care legislation won’t be brought up again this year; there is too much instability in the individual insurance market under the ACA to expect the problem to resolve itself without a significant policy intervention. Republican leaders should look again at the AHCA and correct the flaws that made it difficult to pass in the first place. As a replacement for the individual mandate, the AHCA as written would have imposed a new, one-year 30 percent surcharge on premiums for customers who have experienced more than a two-month break in their insurance enrollment over the previous year. A major flaw is that the surcharge is not adjusted to correspond to the length of the spell without insurance.
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President Donald Trump’s core principles for health care include ensuring that Americans with pre-existing conditions have access to coverage, and that Americans should be able to purchase the health insurance plan they want, not one forced on them by the government. Each of these goals is laudable and achievable, taken separately. But President Trump and others are about to confront what others have learned the hard way: Achieving both goals simultaneously is extremely challenging.
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Let the states derive their own health care solutions, particularly when it comes to cost containment. That’s why we may need to look to six states that are aggressively working to contain costs. The Florida, Georgia, Alabama and Tennessee legislatures are considering a proposal to eliminate defensive medicine by abolishing each state’s medical malpractice system and replace it with a no-blame model similar to workers’ compensation. Two other states are also examining the concept. When doctors are no longer the target of litigation, they would be less likely to order unnecessary tests, medications and procedures.
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The combination of high-deductible insurance with Health Savings Accounts (HSAs) is central to a market-driven reform of U.S. health care. There is, however, a problem with existing HSA policy that must be fixed if HSAs are to reach their full potential in improving the efficiency of health care arrangements: As currently structured, HSAs are not built to provide easy access to care from well-organized systems of health care. Rather, HSA enrollees buy services on a fee-for-service basis, which is, in most cases, a much less efficient way of getting needed care. The rules governing HSAs should be modified to allow account holders to buy access to care from integrated care systems on a fixed-fee basis.
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President Donald Trump’s administration made explicit this weekend its commitment to an old GOP strategy for managing Medicaid, the federal-state insurance plan that covers low-income people — turning control of the program to states and capping what the federal government spends on it each year.
It’s called “block granting.” Right now, Medicaid, which was expanded under the 2010 health reform to insure more people, covers almost 75 million adults and children. Because it is an entitlement, everyone who qualifies is guaranteed coverage and states and the federal government combine funds to cover the costs. Conservatives have long argued the program would be more efficient if states got a lump sum from the federal government and then managed the program as they saw fit. But others say that would mean less funding for the program —eventually translating into greater challenges in getting care for low-income people.
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After eight years Republicans are finally in a position to repeal the Affordable Care Act. Many caution that repeal without concomitant replacement will lead to chaos in the insurance markets with millions losing coverage. These fears are overstated. Yet replacement should accompany repeal for another reason – to maximize the chance that a good replacement package can be enacted.
Republicans hold 52 Senate seats. While a repeal of much, but not all, of the ACA can occur with a simple majority vote through the reconciliation process for items with budgetary implications, repealing the entire law and enacting a replacement will require 60 votes. Republicans need help from at least eight Democrats. They have the best chance of getting it if they combine repeal with a comprehensive replacement package that includes individual items that appeal to specific Democrats who will, therefore, be willing to vote for the entire package.
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President Obama will be leaving office with the Affordable Care Act, his signature policy initiative, in deep peril. An incoming Republican president and Congress, concerned with the cost of ACA exchange plans jumping by an average 25 percent next year and employee health care costs rising, have pledged to repeal the law. For his part, the President sought to shift the blame for rising out-of-pocket cost from the ACA’s flaws to employers and insurers. During a recent speech defending the law, he said the ACA has had no impact on the affordability of employer-provided health care benefits “except to make it a better value.” As the President put it, “if your premium is going up, it’s not because of Obamacare. It’s because of your employer or your insurer — even though sometimes they try to blame Obamacare for why the rates go up. It’s not because of any policy of the Affordable Care Act that the rates are going up.”
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Throughout the campaign, President-Elect Donald Trump’s entire health message consisted of promising to repeal the Affordable Care Act.
That remains difficult with Democrats still commanding enough power in the Senate to block the 60 votes needed for a full repeal. Republicans could use fast-track budget authority to make some major changes to the law, although that could take some time. In the short term, however, Trump could use executive power to make some major changes on his own.
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The presidential election outcome itself could create more problems for the ACA. The insurance plans sold on the law’s exchanges have already experienced substantial losses due to adverse selection, leading many insurance companies to pull back on their participation. The prospect of a Trump administration steering ACA implementation may be enough to convince some of the insurers still offering products on the exchanges in 2017 to rethink their plans. If more insurance companies head for the exits, the exchanges could become even less stable than they already are.
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