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The Wisdom of Experience: Jon Kingsdale on why not to repeal the ACA

The Wisdom of Experience: Jon Kingsdale on why not to repeal the ACA

December 20, 2016

Jon Kingsdale can rightfully hold the title of senior implementor of health reform in the country, As the first Executive Director of the Massachusetts Health Connector, Jon had to figure out from scratch how to set up our health care marketplace in way that would be affordable, efficient, and would rely on competition among private insurers to offer coverage.

Today, Jon published a thoughtful article that builds on the wisdom he gained from years of experience. Titled, "Republicans are about to learn just how much Americans hate health care changes, he makes the bold forecast that the best days of the ACA may still be ahead of us. He identifies the central dilemma of the repeal effort - while the ACA as a concept is not that popular, many of its features have broad support, and tens of millions of people rely on it for affordable coverage. And nobody likes changes to their health care:

While it may be unlovable, the ACA is firmly established — written into the costly software and strategic plans of hundreds of insurers, thousands of hospitals, and the 32 states that expanded Medicaid. If Republicans upend those apple carts, they’ll make a lot of Americans very nervous.

Republicans will struggle mightily over how to replace the ACA’s budget-balanced, market-oriented reforms with something far less regulated and subsidized that doesn’t throw millions of Americans off coverage. Then they must persuade at least eight Democratic senators to support their alternative. If bipartisan reform were easy, it would have happened decades ago, when the country was far less divided, or in 2009 when Senate Democrats last tried.

So, where does that leave the ACA? Pretty darn hard to repeal and replace. But doing nothing seems equally untenable: Either the Republicans fund the ACA, leading Tea Partiers to call for their heads — and everyone else to wonder how they can support a law they revile — or they preside over an insurance crisis. If they defund it, Americans will see just how much they really had to lose. And Republicans will no longer have Obama to blame.

Alongside Jon's appeal to practicality, there's also politics and policy, On the politics side, Noam Levey of the LA Times reported last week on the dwindling constiuency for repeal: 

As they race to repeal large parts of the Affordable Care Act, President-elect Donald Trump and congressional Republicans are leaving behind nearly everyone but their base voters and a handful of conservative activists.

Not a single major organization representing patients, physicians, hospitals or others who work in the nation’s healthcare system backs the GOP’s Obamacare strategy.

New polls also show far more Americans would like to expand or keep the healthcare law, rather than repeal it.

Even many conservative health policy experts caution that the emerging Republican plan, which calls for a vote in January to roll back insurance coverage followed by a lengthy period to develop a replacement, could be disastrous.

That potential disaster is explained well in Sunday's New York Times economics column by Robert Frank, "Want to Get Rid of Obamacare? Be Careful What You Wish For." Frank explains that Republican policy thinkers object most to the individual mandate, and to the sliding scale tax credit subsidies that allow moderate income people to afford coverage. But, as the Massachusetts experience shows, both are essential:

The same logic explains why private/government hybrid programs — like Obamacare, and its predecessor in Massachusetts, Romneycare — include an individual mandate. Opponents of the mandate argue that it limits individual freedom, which of course it does. But traffic lights and homicide laws also limit individual freedom; everyone celebrates liberty, but sometimes we must choose among competing freedoms. Failure to include a mandate would eliminate the freedom of citizens to purchase affordable health insurance. In such cases, we must decide which of the competing freedoms is more important.

The third feature of Obamacare (and Romneycare) is that both provide subsidies for low-income people. You simply cannot require people to buy something they cannot afford.

In short, it’s logically impossible to cobble together a private-insurer-based replacement for Obamacare that offers affordable coverage to people with pre-existing conditions without also including an individual mandate and subsidies. That’s why, despite scores of House votes to repeal it, no one has come forward with a coherent proposal to replace it. Hence the dilemma currently facing Republicans.

All three of these recent articles reach related, overlapping conclusions to some extent, and all are worth looking at. Massachusetts has a unique role in the upcoming debate. Because our 2.8% uninsurance rate is the best in the country, we are the prime example of how good implementation of health reform can work. And, because of that, in some sense we have the most to lose under repeal. We need you to join the effort to protect our care. Sign up here to join the campaign.

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