THE OTHER MARCH MADNESS: What's next for Obamacare? My Final Four predictions

If the AHCA was a college basketball team, many were happy to see “those guys” get knocked off the bracket.  The AHCA will not ‘advance to the finals’ but there are still very different proposals and outcomes in play. And you might not like that team either.

Late last Friday, the House Republican bill to repeal the Affordable Care Act was pulled - the AHCA was eliminated. For very different reasons, almost no one (only 17%) really liked the AHCA and both sides had good reason to claim victory. While I understand the reason for jubilation, the game is hardly over. The AHCA is gone but the ACA repeal efforts won't go away that easily. To keep it in March Madness basketball terms, there is much more game to be played. Of course fixing our broken healthcare system is not a game. The consequences of the rushed AHCA bill would have left millions of Americans without coverage and likely hastened the collapse of the individual market. For now, the ACA has survived another round.

The Final Four:

Yes, I am stubbornly sticking with this corny March Madness theme and offer these four possible outcomes for what is next with the repeal or repair of the ACA.

1.)  “Let Obamacare Explode”

To me, this is the most irresponsible statement and scariest scenario. I try not to take all of Trump's statements literally but as carriers are currently deciding their participation in the exchanges for 2018, more insurers could take that as a warning and opt out. The administration could also use the broad authority of the HHS Secretary (Tom Price) and the CMS Office (Seema Verma) to weaken and even hasten the failing of the ACA, by:

• Halting the ACA cost-sharing subsidies for low-income people. These payments reduce the deductibles and co-pays for more than half of enrollees on the ACA exchanges. Republicans already won a lawsuit in May 2016 but the cost-sharing payments have continued while the suit is being appealed. Watch this closely.
• Weakening the insurance market by not enforcing the individual mandate. Several insurance carriers withdrew from entire states (almost all states where Medicaid was not expanded) because the risk mix was unfavorable. It would get worse if the administration does not enforce the mandate.
• HHS could exempt more groups of people from the individual mandate using the “hardship exemptions.” The risk pool is weaker if healthier risk is exempted.
• CMS/CCIIO could allow insurers to provide health policies in the federal marketplace (FFM) that don’t meet federal standards... like all of the Essential Health Benefits.

2.) “If the people really like the ACA, then the GOP could own it and fix it”

Republicans have learned much from their constituents at angry town halls, like how it is the only way premiums are immediately affordable for many, especially in the 32 states that expanded Medicaid. The GOP could take ownership of the ACA and strengthen the individual insurance market. The GOP could also take credit for keeping the cost-sharing subsidies intact that insurers offer low-income Americans.

• At least 17 states have only one or two carriers in the individual market. So Republicans could get to work on solutions (at a state level) to examine the market factors or other reasons why carriers won’t participate and attempt to restore the individual market. (but it could mean more states expanding Medicaid like Republican-led Kansas just announced.)
• The administration could use the HHS and CMS authority to shore up other pain-points for insurance carriers including stronger verification for late enrollments through Special Enrollment Periods, and shorter grace periods to mitigate the potential for gaming the system and “free-riders” who only pay for a few months of coverage while technically being eligible all year. Insurers also need help from the administration to create new ways to attract younger and healthier people to offset the costs of the older, more expensive individuals. Work with the carriers.

3.)   “If at first you don’t succeed… Repeal, repeal again”

Almost immediately, some Republicans promised to keep trying to repeal Obamacare. But they have yet to agree on a goal. Regroup and decide what winning looks like before advancing a bill. Satisfying both ends of the divided GOP won’t be easy. 

However, House Republicans did pass a repeal bill in 2015 that Obama vetoed (Price’s  “Restoring Americans’ Healthcare Freedom Reconciliation Act of 2015,”) so it’s possible. After a break and regrouping, the GOP could take another pass with this bill or take more time to draft a new bill.  This seems unlikely to happen anytime soon.

4.)  “Work with Democrats – Let The States Decide”

Don't laugh. It could happen. But it is hard to read the mood in Washington D.C. and if either side really wants to collaborate on a bipartisan solution. (I got mixed messages when I met with legislators in the Capitol with NAHU in February) Both said they would work across the aisle but statements like this don't exactly invite bipartisanship:

"When it explodes they [Dems] come to us and we make one beautiful deal” - President Trump 3/25/17

Democrats have been willing to work with Republicans, as long as it is a plan to repair the ACA, not repeal. But now Dems have little political incentive to help the GOP save face. Experts say Democrats could pick up 27 to 53 House seats during the 2018 mid-term elections, depending on Trump's approval rate at the time of election (currently around 36%). Still, leading Dems like Chuck Schumer (NY) suggested they could get progress on smaller repair fixes like lowering prescription drug costs, something the administration said they also want.

“That’s something we can work with (the president) on,” House Minority Leader Nancy Pelosi, D-Calif.

Since Republicans are largely divided based on who expanded Medicaid and who did not, maybe the most likely solution could be to look for ways to shift more of the responsibility and choices to the states. You might remember a promising GOP Senate bill called The Patient Freedom Act of 2017, co-sponsored by Bill Cassidy (R-La.) and Susan Collins (R-Maine).  Their compromise bill would allow states to keep the ACA if they like it, or opt-out for a different solution. Because this was not a full repeal, the GOP opted to move forward with the more-aggressive AHCA. After a break, the GOP revisit this model but the next attempt seems unlikely to be lead by Paul Ryan, who suffered some loss of credibility for his all-in support of the AHCA.

• Price and Verma Verma could use the Medicaid 1115 waivers to approve state plans that deviate significantly from traditional Medicaid (like Pence did in Indiana). But, I think this could be how 'work requirement' is added without a vote from Congress.
• She could also consider how state innovation waivers (Section 1332 of the ACA) have worked and assess what might work in similar states. Through the 1332 waiver, the ACA permits states to apply for “State Innovation Waivers to pursue innovative strategies for providing… affordable health insurance while retaining the basic protections of the ACA.”

THE WILDCARD

Since the Trump presidency has been full of surprises and unpredictable comebacks and twists, I should consider a possible longshot. Trump has described an appreciation for universal coverage in recent interviews. He once embraced the Canadian-style single payer system, but since adopted the more traditional GOP script and talking points. Based on his earlier statements, he could support a plan which provides a private employer-based system with (for individuals) a Medicare-for-all, or a universal Medicaid base plus Medicare buy-in for people over 50. Reminds me of a plan Hillary Clinton proposed during the 2016 campaign.

Over the years, Trump as been for and against single-payer. He is against government health care but likes a universal health care system that covers everyone and when asked how to fund it said, "the government's gonna pay for it". This broad ideological swing makes him hard to predict and could change the GOP narrative.

In 1999, when Trump was thinking about a run for president, he told Larry King:

“If you can’t take care of your sick in the country, forget it, it’s all over... I believe in universal healthcare.”

In 2000, Trump wrote a book called The America We Deserve, in which he praised universal healthcare systems:

"We must have universal healthcare...I'm a conservative on most issues but a liberal on this one. We should not hear so many stories of families ruined by healthcare expenses...

Doctors might be paid less than they are now, as is the case in Canada, but they would be able to treat more patients because of the reduction in their paperwork..

The Canadian plan also helps Canadians live longer and healthier than Americans. There are fewer medical lawsuits, less loss of labor to sickness, and lower costs to companies paying for the medical care of their employees. If the program were in place in Massachusetts in 1999 it would have reduced administrative costs by $2.5 million. We need, as a nation, to reexamine the single-payer plan, as many individual states are doing."

In 2015, “As far as single payer, it works in Canada. It works incredibly well in Scotland. It could have worked in a different age, which is the age you’re talking about here.”

In Jan 2017: "We’re going to have insurance for everybody,” Trump said. “There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.” People covered under the law “can expect to have great health care. It will be in a much simplified form. Much less expensive and much better.” – Washington Post  interview

I don't mean to make light of this important political debate by using sports comparisons. Truth is, I only watch college basketball during the final four. Like most of you, I am too busy with other stuff and even busier trying to keep track of the health care reform changes which affect my business and fuel my passions as an advocate. Unlike the NCAA basketball tournament, we could have an outcome that aims at all winning something. But that’s not the game we are playing. Let’s change the game. 

(Go Oregon!)

---------------------------------------

Michael Lujan is a volunteer advocate for the uninsured and small business. A health insurance industry veteran of thirty years, Michael is past president at CAHU.org and currently serves on the board of the California School-Based Health Alliance, a non-profit organization providing healthcare clinic at school locations. He is also a co-founder at Limelight Health, an insurance technology software startup based in San Francisco.

* Views and opinions my own