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Op-Ed: Yes, We Should Change the Affordable Care Act — to Keep It

The powerful lies and deceptions about why the ACA should be scrapped did their job, as did the unbelievable ineptitude of the Democrats and the press

richard f. keevey
Richard F. Keevey

The Affordable Care Act (ACA) is under serious threat. Its impending doom is not because it is suffering — actually, signups have increased — but because Republican leaders simply wish to keep their promise to eliminate Obamacare. No one has proposed any option other than some vaguely suggested “market approach.” But America and New Jersey need the ACA in some form.

The principal argument raised during the presidential campaign was large premium increases. But these increases affected less than 0.06 percent of Americans. I speak to a lot of seniors (yes, I am one) and 95 percent complained about insurance premium increases. But when I reminded them they were on Medicare and not affected they shook their heads — they still wanted to eliminate this “give-away” program.

Further, they were dumbfounded when I informed them the ACA actually helped them. The closing and ultimately the elimination of the “donut hole” in their prescription drugs was part of the ACA — as was the expansion of free preventive services, such as screening for colon, prostate, and breast cancer. This is also true of annual wellness visits. The powerful lies and deceptions about the ACA worked, as well as the unbelievable ineptitude of Democrats and the press.

The ACA has significantly reduced the number of uninsured in the United States. Of the approximately 22 million now covered by the law (535,000 in New Jersey), only 10 million achieved new coverage via insurance networks in which premium payments were required. Most new coverage was achieved via Medicaid. And for the folks paying insurance premiums, 86 percent received subsidies that reduced costs significantly.

In addition to these 22 million, countless other Americans benefited because insurance companies can no longer deny coverage based on preexisting conditions, and young adults remained on their parents’ health coverage until age 26. Think of the number of college students and unemployed young adults who benefit, especially in economic downturns.

Another result is the very positive impact that the ACA has on hospitals. Previously, all uninsured folks were admitted to hospitals as “indigent-care” patients via the emergency room. Hospitals absorbed these costs creating instability. The 22 million-plus are now payers, and hospital-indigent costs are significantly reduced. Ask any hospital CEO what he or she thinks of the ACA.

But I suggest that Democrats think of ways to work with the Republicans to retain but necessarily alter the ACA. It may not be what is best, but both sides can come out winners, and folks will not lose coverage. I am no health expert, but many exist and as a group they can fix the basic framework and satisfy political ideologues.

Fortunately, the basic structure of the ACA features consumer choice among competing private health plans that market-oriented Republicans can support. But keeping the subsidy concept — in some form — is critical. Supporters also must craft a deal that relaxes the age rules and mandatory requirements to make it more attractive for younger, healthier people to buy at least bare-bones insurance. This would give them strong incentives to enroll (an actuarial necessity) without an actual mandate, a Republican “no-no.” One solution: Allow insurance companies to make modest profits by offloading the costs of the very sick into some sort of government-subsidized reinsurance high risk pool.

Other Republican ideas could be accepted. For example, carefully constructed interstate insurance pools could help address the always-vexing problem of covering rural areas and perhaps increase competition. Also, expanding use of health savings accounts (HSAs) — which Democrats argue only helps certain groups — could be a good compromise. A carefully constructed and targeted HSA could augment subsidies. Further, medical malpractice reform in some form could be part of a compromise. Finally, the signup process must be streamlined and simplified, and some of the regulatory burdens need to be reduced.

Most important — the Medicaid part of the ACA must be maintained — and hopefully, adjusted in such a way that encourages all states to join the program (only 31 states, including New Jersey, have joined). Medicaid provides the broadest coverage and the administrative apparatus is very effective and inexpensive.

Some Republicans want to turn Medicaid into a block-grant program to cap funding and limit services, including healthcare for children and nursing-home care for the elderly and disabled. Such an approach is a poor alternative; states are fiscally stressed and can’t afford such a tradeoff. But some thoughtful ideas such as expanding the Medicaid waiver process already in the law could reduce costs without changing the basics. Other health-saving options are essential; what about allowing Medicare to negotiate drug prices as Medicaid already does?

Expanded health coverage under any option is not without cost; to argue otherwise would not be honest and would exacerbate the nation’s debt. Therefore, I would argue that the two tax increases that are part of the ACA statute, both impacting only families above the $250,000 income level, be maintained. Eliminating them would further exacerbate the debt situation.

This issue needs to be addressed immediately: no repeal with a vague promise to replace later. Not only would 22 million-plus lose coverage, but the market for individual insurance and hospital viability might very well implode. We can make a deal —there is a win-win scenario here and we can emerge with a revised and viable plan. The program name is not important; the extent of coverage is.

Richard F. Keevey is the former OMB director for two New Jersey governors — from both political parties; he also held presidential appointments as the deputy undersecretary of defense and the CFO at HUD. Currently, he is a senior policy fellow at the Bloustein School of Planning and Policy at Rutgers University and a lecturer at Princeton University.

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