The Future of the ACA Four Years Later – and The Perils of Being A Futurist.

Posted on | September 29, 2020 | 2 Comments

Mike Magee

Tonight we witness the first Presidential debate of 2020, and the future of the ACA (in the middle of a pandemic) is once again on the line. If past is prologue, make predictions of the outcome at your own risk.

Four years ago, 1 month before the election, the New England Journal of Medicine served as a platform for dueling visions of the outcome. UNC’s Jonathan Oberlander penned the fallout of a Democratic win, while Gail Wilensky presented the Republican version. Both landed far afield of what has happened since.

October, 2016

A Democratic Victory: by Jonathan Oberlander

1. While the ACA has resulted in a decline in the nation’s uninsured rate from 48 million to 27 million, the rising cost of insurance, especially for those at the upper levels of poverty (200% of the Federal Poverty Limit), where a family plan on average now costs more than $20,000 a year, is untenable. Translation: some changes will be required to address their needs.

2. There is also a problem with rising deductibles. This averaged $303 in 2006, but hit $1,077 in 2015. Hillary Clinton’s plan is to provide a refundable tax credit for citizens with high out-of-pocket deductibles.

3. Three major insurers (UnitedHealthcare, Humana, and Aetna) are planning to curtail their involvement with the ACA exchanges. They complain that the pricing differential they are allowed between the healthiest and sickest enrollees (3 to 1) is not adequate to cover their financial risk. In their view, we should go back to 5 to 1. It is unlikely they will force the government hand on this, any more than reversing the provisions that prevent exclusion based on prior conditions. Instead their stance will likely move both the federal government and state governments toward “public options”, whether through downward extension of age eligibility for Medicare, or expansion Massachusetts-like universal coverage plans to other states.

4. A Democratic victory would likely cause most Republican led states that have resisted Medicaid expansion under ACA to give up their resistance. Their abandonment of a stance that has been financially self-destructive to their states could be hastened by changes that assure permanent, near 100% federal funding of Medicaid into the future. This would come with greater standardization of rules nationwide governing the coverage package. Any move toward nationalization would carry with it more focus on cost and efficiency, with data transparency leading the charge to address price gougers, research result hiders, sloppy prescribers, and outcome outliers.

A Republican Victory: by Gail Wilensky

1. Gail Wilensky predicts the likely outcome of the presidential race to be a Democratic victory, with the House remaining under Republican control, but the Senate majority potentially shifting to the Democrats. In this light, she outlines the current Paul Ryan’ health care plan versus Donald Trump’s which bundles an outright repeal of the ACA with allowance of drug reimportation and negotiation of Medicare Part D drug prices.

2. Were the Ryan plan to be implemented, unchanged by a Democratic controlled Senate or presidential veto, we could expect:

a) Medicare age eligibility would gradually increase to age 67, and Medicare would become a “premium support” , partially privatized program.

b) High deductible plans, which deliberately increase consumer focus on cost, would be promoted through government supported Tax Savings Accounts, housing tax-exempt funds to cover excess medical costs.

c) The current prohibitions on exclusion for prior conditions or excessive cost profiles would remain in force. But insurers would be allowed a 5 to 1 cost ratio spread based on age.

d). Medicaid would be funded by a federal grant at “X” dollars per person, and states would have substantial leeway on how to prioritize spending as well as the ability to require “able bodied adult recipients to work”.

September 29, 2020

Our current ACA reality:

Trump is trying for a second term.
The ACA is still alive, though Trump and Republicans are still trying to kill it. The latest gambit – stack the Supreme Court with a conservative majority. His alternative? Still not clear.
Large majorities of Americans now support universal health coverage, protection for pre-existing conditions, and a comprehensive basic benefit package.
Only 12 deep red states continue to pass on the extended Medicaid offering built into the ACA.
Medicare eligibility remains at age 65, and there is active debate whether the country should move to a “Medicare-for-all” plan.
Cost of health care annually now approaches $4 Trillion, with approximately 25% (in multiple studies) wasted, and qualities outcomes far short of other developed nations.
There are 16 health care workers for every one physician in America – and at least half of these have absolutely now clinical “hands-on” care role.

What will happen next?

Predict at your own risk.

Comments

2 Responses to “The Future of the ACA Four Years Later – and The Perils of Being A Futurist.”

Art Ulene
September 29th, 2020 @ 12:51 pm

Wow! Thanks for reminding us.
Mike Magee
September 29th, 2020 @ 5:43 pm

A blessing for all pundits…it’s so easy to forget!