Source: Gary Claxton, Larry Levitt, and Karen Pollitz, Kaiser Family Foundation, Issue Brief, February 2017
From the overview:
Significant changes to the Affordable Care Act (ACA) are being considered by lawmakers who have been critical of its general approach to providing coverage and to some of its key provisions. An important area where changes will be considered has to do with how people with health problems would be able to gain and keep access to coverage and how much they may have to pay for it. People’s health is dynamic. At any given time, an estimated 27% of non-elderly adults have health conditions that would make them ineligible for coverage under traditional non-group underwriting standards that existed prior to the ACA. Over their lifetimes, everyone is at risk of having these periods, some short and some that last for the rest of their lives.
One of the biggest changes that the ACA made to the non-group insurance market was to eliminate consideration by insurers of a person’s health or health history in enrollment and rating decisions. This assured that people who had or who developed health problems would have the same plan choices and pay the same premiums as others, essentially pooling their expected costs together to determine the premiums that all would pay.
Proposals for replacing the ACA such as Rep. Tom Price’s Empowering Patients First Act and Speaker Paul Ryan’s “A Better Way” policy paper would repeal these insurance market rules, moving back towards pre-ACA standards where insurers generally had more leeway to use individual health in enrollment and rating for non-group coverage.1 Under these proposals, people without pre-existing conditions would generally be able to purchase coverage anytime from private insurers. For people with health problems, several approaches have been proposed: (1) requiring insurers to accept people transitioning from previous coverage without a gap (“continuously covered”); (2) allowing insurers to charge higher premiums (within limits) to people with pre-existing conditions who have had a gap in coverage; and (3) establishing high-risk pools, which are public programs that provide coverage to people declined by private insurers…..
Compare Key Elements of ACA Repeal and Replace Proposals with New Interactive Tool
Source: Congressional Research Service, CRS Reports & Analysis Legal Sidebar, January 24, 2016
On January 20, 2017, President Donald J. Trump issued an executive order (EO) declaring his intention to “seek the prompt repeal of the Patient Protection and Affordable Care Act [ACA]” while minimizing “economic and regulatory burdens of the Act,” ensuring that the ACA is “efficiently implemented,” and preparing to allow states “more flexibility and control.” Broadly, the EO issues the following three directives to executive branch agencies:
– First, it directs agencies with authorities or responsibilities under the ACA to “waive, defer, grant exemptions from, or delay the implementation of” any ACA provision that would impose a fiscal or regulatory burden on states or a host of private entities (including individuals, health care providers, health insurers, and medical device manufacturers).
– Second, the EO directs those same agencies to provide greater flexibility and cooperation to states in implementing healthcare programs.
– Third, the EO directs all agencies with responsibilities relating to healthcare or health insurance to encourage the development of a free and open interstate market for health services and health insurance…
Source: Kaiser Health News, 2017
President-elect Donald Trump has promised to “repeal and replace” the Affordable Care Act, but has offered few details about what comes next. That’s why Kaiser Health News is launching Repeal & Replace Watch to track the new administration’s plans to revamp America’s health care system.
With a steady stream of analysis, explanation, investigation and data, Repeal & Replace Watch will follow how the new politics of health care are playing out here in D.C. We’ll also report on how the changes in Washington affect patients, hospitals, doctors and insurers across the country.
Source: Leighton Ku, Erika Steinmetz, Erin Brantley, Brian K. Bruen, Commonwealth Fund, Issue Brief, January 2017
From the abstract:
Issue: The incoming Trump administration and Republicans in Congress are seeking to repeal the Affordable Care Act (ACA), likely beginning with the law’s insurance premium tax credits and expansion of Medicaid eligibility. Research shows that the loss of these two provisions would lead to a doubling of the number of uninsured, higher uncompensated care costs for providers, and higher taxes for low-income Americans.
Goal: To determine the state-by-state effect of repeal on employment and economic activity. Methods: A multistate economic forecasting model (PI+ from Regional Economic Models, Inc.) was used to quantify for each state the effects of the federal spending cuts.
Findings and Conclusions: Repeal results in a $140 billion loss in federal funding for health care in 2019, leading to the loss of 2.6 million jobs (mostly in the private sector) that year across all states. A third of lost jobs are in health care, with the majority in other industries. If replacement policies are not in place, there will be a cumulative $1.5 trillion loss in gross state products and a $2.6 trillion reduction in business output from 2019 to 2023. States and health care providers will be particularly hard hit by the funding cuts.
View job loss by state
State Fact Sheets
Source: J.B. Silvers, The Conversation, December 29, 2016
….To entice insurers into the market, the ACA also offered well-established methods to reduce risk. For example, it built in protections for insurers who enrolled especially sick people. It also provided back-up payments for very high-cost cases and protected against big losses and limited big gains in the first three years.
These steps worked well in establishing a stable market for Medicare drug plans when this program started under President Bush in 2006. Competition there is vigorous, rates are lower than estimated and enrollees are satisfied. In other words, the market works well…..
…..But when the time came to pay up for risk reduction in the Obamacare exchanges, Congress reneged and paid only 12 percent of what was owed to the insurers. So, on top of the fact that the companies had to bear the risk of unknown costs and utilization in the start-up years, which turned out to be higher than they expected, insurers had to absorb legislative uncertainty of whether the rules would be rewritten.
It is no wonder that this year they have dramatically increased premiums, averaging 20 percent, to compensate for the extra risk they didn’t factor into the original lower rates. In contrast, underlying health costs are rising at about 5 percent…..
Source: Thomas Huelskoetter, Center for American Progress, December 9, 2016
Congressional Republicans currently plan to repeal much of the ACA early next year. Here is what would happen should they proceed.
Source: Center on Budget and Policy Priorities, December 7, 2016
Some 29.8 million people would lose health insurance coverage if the Affordable Care Act is repealed, data from the Urban Institute show. These fact sheets provide state-by-state data on the number of people who would lose coverage and the loss of related federal funding.
Republican Health Reform Repeal Plan Would Leave 30 Million More Uninsured
Source: Center on Budget and Policy Priorities, December 7, 2016
Commentary: GOP’s Health Reform Strategy Amounts to Repeal Without Replacement
Source: Center on Budget and Policy Priorities, December 5, 2016
Source: California HealthCare Foundation, November 2016
From the summary:
With Donald Trump as president and a Republican-controlled Congress, the ACA is in jeopardy of being partially or completely repealed. In light of these potential changes, what does California stand to lose?
Source: Timothy Callaghan, The Conversation, October 25, 2016
….Given these facts, it is important to ask: Why isn’t universal coverage through a national health insurance system even being considered in America? Research in health policy points to three explanations.
No. 1: We don’t want it
….In other words, Americans, and conservatives in particular, have a strong belief in classical liberalism and the idea that the government should play a limited role in society……
No. 2: Interest groups don’t want it
….The insurance industry was a key player in this process, spending over $100 million to help shape the ACA and keep private insurers, as opposed to the government, as the key cog in American health care……
No. 3: Entitlement programs are hard in general to enact
….The political system is prone to inertia and any attempt at comprehensive reform must pass through the obstacle course of congressional committees, budget estimates, conference committees, amendments and a potential veto while opponents of reform publicly bash the bill……
Source: Erin C. Fuse Brown, Hastings Law Journal, Vol. 67 No. 1, 2015
From the abstract:
Our excess health care spending in the United States is driven largely by our high health care prices. Our prices are so high because they are undisciplined by market forces, in a health care system rife with market failures, which include information asymmetries, noncompetitive levels of provider market concentration, moral hazard created by health insurance, multiple principal-agent relationships with misaligned incentives, and externalities from unwarranted price variation and discrimination. These health care market failures invite a regulatory solution. An array of legal and policy solutions are typically advanced to control our health care prices and spending, including: (1) market solutions that focus on transparency and consumerism to discipline health care prices; (2) antitrust enforcement to promote competition in the provider market; (3) consumer protections that protect individual uninsured or underinsured patients from unfair prices; (4) health care payment and delivery reforms that alter financial incentives of health care providers to reduce overutilization and improve efficiency; and (5) direct regulation of provider payment rates. The literature on these health care policy approaches reflects the fragmentation of the U.S. health care system, typically considering each approach in isolation, and it is difficult to make sense of an a la carte menu of approaches. This article sets forth an analytic framework to simultaneously and comprehensively evaluate all the policy solutions to discipline health care prices by measuring each solution for its ability to address the health care market failures. Applying this policy-against-market failure analysis leads to the following conclusion: only one solution – direct rate regulation – is capable of addressing the widespread and growing provider monopoly problem. More politically popular market approaches such as price transparency and payment and delivery reforms can correct the market failures from information asymmetries and principal-agent problems, but because they do not address the market power of providers, they will be ineffective to control health care prices and spending without accompanying direct rate regulation. It is time to resurrect rate regulation and place it squarely in the center of any policy strategy to control health care prices and spending.