Taking Stock Of Health Reform: Where We’ve Been, Where We’re Going
By Timothy Jost
Health Affairs Blog, December 6, 2016
Almost from the moment of its inauguration in 2009, the Obama administration has struggled, often against adamant resistance, to enact and implement the Affordable Care Act (ACA). The 2016 election has brought to power opponents of the ACA who will control the presidency, both houses of Congress, and many state houses and governorships. ACA repeal, or “repeal and replace,” seems to be a very real, indeed likely, possibility. It is important, therefore, to take a sober look at what the ACA has achieved in its nearly six years of existence, and what repeal, or repeal and replacement, might look like.
(Use the link below to see a precise explanation of what ACA has achieved and what repeal and replace might look like.)
The ACA has made many Americans better off, and can boast of important achievements. In particular, it has ensured that Americans cannot be denied coverage or have their coverage limited because of health problems. Millions of lower-income Americans are receiving health coverage through Medicaid and the marketplaces who would otherwise be unable to afford coverage. But many still face unaffordable cost-sharing burdens and narrow networks, and many middle-income individuals can no longer afford coverage in the individual market.
While there are real opportunities for the new administration and Congress to improve the ACA, it is essential that they not precipitously undo its achievements. Repeal must await a clear plan for replacement. And the timing of repeal must take into account not only the time it takes to adopt replacement legislation but also the time it takes to write the rules, formulate guidance, and create and staff programs to administer a replacement program. If there is anything we have learned from the last six years, it is that implementation is hard work and takes time.
Careful and objective analysis must be given to replacement proposals and their effects. Many of these are not new but rather resurrect policy initiatives of the past that proved problematic in important respects. They have track records that can be studied. The effects of other proposed provisions can be modeled.
What preliminary analysis of Republican replacement proposals shows is quite clear: they would provide considerably less help for lower-income Americans and people with health problems, and could mean increased costs for these groups. They might at the same time lower costs and provide more assistance for middle- and higher-income Americans. They would shift costs from the federal government to the states. They would shift costs from the government to individuals and families, and to providers. They would make health care less accessible and less affordable to those who have been helped by the ACA, but might make it more affordable to some whom the ACA has not helped.
Elections have consequences, and, arguably, to the victors go the spoils. But transparency is important; no one should be under any illusion that an ACA replacement will make everyone better off — it could cause serious harm and disruption to some who were helped most by the ACA. If Congress and the administration are to embrace this harm and disruption, it is vitally important that the American people understand the consequences.
By Don McCanne, M.D.
Timothy Jost provides an invaluable service by by bringing truth to the dialogue on reform. Those who are satisfied with benefits gained through the Affordable Care Act will have to concede that it has still fallen significantly short of many goals of reform. Those who would replace many or most of the features of ACA will have to be honest about the severe deficiencies of their leading proposals, likely leaving many people worse off. Either way, we will still not end up with the high-performing system that the $3.2 trillion we are spending on health care should be bringing us.
Although it was not the intent of this article to discuss other options for reform than those on which the current political dialogue is focused, nevertheless one other model should be under discussion and that is a well-designed single payer national health program. For the same amount that we are already spending, we could have a high quality system that is truly universal, comprehensive, accessible, and affordable for everyone. At the time of another pending upheaval in our health care system a model that would actually work to achieve these goals clearly should be on the table. Many of the perverse features of a fragmented, dysfunctional multi-payer system discussed in Jost’s article would simply go away.
By Don McCanne, M.D.
There will likely be considerable heat in the discussions ahead on repealing and replacing the Affordable Care Act. Based on current observations, much of it will be clouded with failure to adhere to the actual facts which are based on sound health policy science. This article will be particularly helpful as a resource since Timothy Jost is meticulous with the facts as he explains what has happened and what might happen under the various proposals for replacement.
By reading this fairly long article, you can reinforce your understanding of the issues so that you can help bring truth to the national dialogue on reform. Also you should save the link and make it available to others who wish to have an unbiased understanding of the facts without having to wade through rhetorical embellishment.
When the facts are known, it will be clear that neither the status quo under ACA nor the replacement plans currently under consideration will be adequate to ensure that everyone would have affordable access to essential health care services. That is why we need to be sure that a model that would give us this assurance – single payer – is back on the table, front and center, during our national dialogue on reform.