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By Dennis Gallagher, MA, MPA Associate Teaching Professor Drexel University, Dornsife School of Public Health Department of Health Management and Policy After almost three full years of experience with the Affordable Care Act (ACA), it is clear that changes to the law are necessary if it is to sustain the good things that it has achieved to date. Even bigger changes are called for if it is to attain broader goals of expanding access to affordable health care, constrain the growth in costs, and improve the health of the U.S population. Unfortunately, in the super-charged world of American politics, the chances for meaningful and effective changes to the ACA seem remote, no matter which candidate wins the presidential election.
Let’s break that sad scenario into two parts. If Hillary Clinton becomes President, we should assume that she will advocate for the major changes to the ACA that are in the Democratic party election platform. The most important change, which is also the one least likely to happen, is the creation of a public plan option for persons residing in areas of the country where there are very few or no insurance options in the healthcare marketplace. The argument for the public plan option is to assure access to health insurance and gain the benefits of competition between insurance plans. But the essential Republican philosophical point of opposition to the ACA (beyond the simple political fact that it is associated with President Obama and the Democrats) is that it establishes a large, critical regulatory role for the Federal government in the functioning and oversight of the U.S. health system. Creating a new public plan option would expand the Federal government’s role in, and responsibility for, health care financing. Republican opposition to the public plan option was severe in 2009 when negotiations were underway to draft what would become the ACA, and Democrats in Congress dropped it from consideration when the law was finally drafted and enacted. At best, it’s hard to imagine the public plan option getting a serious hearing in Congress in the next several years, even if the Democrats achieve a majority in the Senate. If Donald Trump becomes President, we should assume that legislative efforts to repeal and replace the ACA with an alternative Republican program, or set of programs, would take on new life and heightened energy. The Republican legislative approach would likely retain some popular elements of the ACA, like guaranteed issuance of health insurance regardless of pre-existing conditions. It would also eliminate the individual mandate to purchase health insurance and employer mandates to provide coverage, expand the role of individual/family health savings accounts to help pay for the purchase of private insurance, offer tax credits for people without employer-based coverage to offset the cost of purchasing health insurance, and create state-based, subsidized high-risk pools for people with expensive medical conditions. A Republican approach would also eliminate the expansion of Medicaid coverage for low-income adults, and instead transform the Medicaid program by giving states the authority to decide how Federal funds would be spent, while also capping Federal funding, annually. The Republican plan would also eliminate the essential health benefits that all individual insurance plans must now provide, allowing instead for the sale and purchase of low cost, minimal benefit, “mini-medical” plans across state lines. Although a President Trump would likely have a Republican majority in both houses of Congress, attempts at repealing the ACA and replacing it instead with a set of programs like those proposed by Republican Congressmen and articulated in the Republican party platform might well be blocked in large measure by the sizable Democratic minority in the Senate. It would take 60 Senators to vote to approve this legislation, and it seems unlikely that Senate Democrats would agree to support these measures – most of which have either been opposed by Democrats for decades – like “block granting” Medicaid -- or which have failed in the past to achieve the desired ends – like state-based “high-risk pools.” So, what can we expect will happen to the ACA after the election? The easy and most probable answer is – not much, certainly not in the short term. Republicans currently have a lawsuit (US House of Representatives vs Burwell) in the works in an attempt to find that the Department of Health and Human Services exceeded its constitutional authority by using funds not appropriated by Congress to pay for cost-sharing subsidies for low-income persons covered by plans in the ACA marketplace. A May 2016 ruling in the D.C. District Court found in favor of the House and is now under appeal. A President Clinton and the Democrats would get little support – or attention -- from Republicans at least not until this court case is resolved in final. At best there might be efforts made afterward on the margins of the ACA, to address several requirements affecting small businesses and their employees. But such changes would be minimal. Congress would likely continue efforts to block appropriations for parts of the ACA, almost certainly ensuring that the ACA never fully achieves its reform potential and likely endangering its continuation because of growing instability in the health insurance market. On the other hand, a President Trump would have to find a way to overcome Democratic Senators who would otherwise block efforts to repeal and replace the ACA with Republican approaches. In that case, one might imagine a long, slow, ugly transition from the ACA to something like a Republican re-casting of it – a scenario that might be necessitated by (successful) Republican measures to strangle funding of key parts of the ACA, as part of the annual budget and appropriations process. What can we almost certainly NOT expect? Sadly, we should not expect true partisanship in reforming the U.S. health system. Health care will remain a battle ground no matter what the election brings. |
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March 2017
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