Building on Obamacare, warts and all


The rhetoric surrounding the Affordable Care Act never seems to die. Most recently, in the second presidential debate, Donald Trump said that, “Obamacare will never work. It's very bad.” And, Hillary Clinton had to explain what Bill Clinton meant when he, while in Flint, called the health insurance exchange—where many working people buying coverage themselves are facing substantial premium increases, high deductibles and limited provider networks—the “craziest thing in the world.”

After nearly six years of dialogue, a Republican plan to repeal and replace the Affordable Care Act (ACA) materialized this summer. U.S. House Speaker Paul Ryan introduced the proposal in June that includes several familiar elements. Moving Medicaid to a block grant program, converting Medicare to a premium support structure, and eliminating the ACA’s individual mandate in favor of adding market-based approaches to encourage the purchase of private health insurance all have been proposed before, and all now appear in Ryan’s proposal.

But the underlying question that remains unanswered in Ryan’s plan is: Do the ACA’s results to date warrant repeal?

It is certainly the case that the health insurance exchange market is not yet stable. The fact that health plans from Aetna and local co-ops to some Blues in other states are leaving the health insurance exchange market is indicative of real problems. But, the reality is that the individual health insurance market, which covers about 5 percent of the nation’s population, has always had serious problems. Indeed, the ACA was put in place in part because many individuals could not get health insurance at all because of pre-existing conditions or other medical issues—even if they were willing to pay for it. Under the ACA, many of those individuals have coverage today.

There is no debate that the ACA has expanded health insurance coverage.

Three recent reports show how much the ACA has accomplished in this regard. The Centers for Disease Control and Prevention reported that the national uninsurance rate was 9.1 percent by the end of 2015, the lowest rate ever since the CDC began collecting these data over 50 years ago, dating to the advent of Medicare and Medicaid.

More than 35 million Americans changed coverage in 2014, most because of the ACA and the availability of new forms of insurance. And the length of time of uninsurance declined, with more people uninsured for 1 to 3 months and fewer people uninsured for 12 months or more.

According to recent data from the U.S. Census Bureau, in Michigan, the uninsurance rate was 6.1 percent in 2015, down from 11 percent in 2013.

Similar to national trends, in 2015, fewer people reported being uninsured for long periods than in 2014. Michigan’s lower percentage of uninsured compared to the country as a whole continues the state’s long tradition of fostering a supportive climate for health insurance. Indeed, Michigan’s pragmatic approach to ACA implementation and the state’s decision to expand its Medicaid program through Healthy Michigan were important contributors to our state’s lower rates of uninsurance.

The individual insurance market is still in transition. Health plans are leaving the market and premiums are increasing substantially in many areas in the country as insurers better understand utilization trends among the enrolled population. Some of the decisions that have been made to encourage coverage (in particular, the breadth of the special enrollment periods) have meant that many insurers have seen a sicker patient mix than they expected. Health plans that are staying in the individual market are raising premiums and limiting the provider networks they offer.

As a result, coverage doesn’t always equal access to care, as many individuals have deductibles or copayments that still make care unaffordable for them. Indeed, in a study that my Center did in Washtenaw County, Mich., more people are now underinsured (11.3 percent) than uninsured (7 percent). While these percentages will vary across the state and country, surveys confirm that more people are now considered underinsured than uninsured in Michigan.

Both sides of the political spectrum can agree that implementation of the ACA has not always been smooth. Conservatives argue that states are not given enough flexibility by the administration to implement Medicaid expansion how they want, and liberals argue that the law’s narrow definition of affordable coverage leaves many lower- and middle-income families without assistance to help buy health insurance.

Clearly, the ACA needs changes. More needs to be done to stabilize the health insurance exchange market through both regulatory changes and perhaps increased consumer subsidies. Reaching those who are eligible for coverage but not enrolled; making care more affordable so that those with coverage have access to care; continuing to improve quality, reduce unnecessary and harmful care while improving access to needed services are all continuing challenges in the U.S. healthcare system.

The ACA includes many demonstration projects and innovations to test new ideas on provider payments and quality incentives. In addition, many private health plans and state Medicaid programs are innovating with new approaches to integrating the medical care and human services systems; new strategies to improve delivery of mental health services; and designing benefit plans that are intended to encourage the use of higher value services and reduce the use of relatively low-value services. These efforts show tremendous promise and potential to make sustained and positive changes in our healthcare system.

The ACA is not perfect, but it gives the framework to address these problems and test new ways of delivering care that did not occur in the past. Repealing the ACA would eliminate the gains that have been achieved without fixing the problems that exist.

It’s time to get down to the work of improving the ACA. Is it too much to hope that we might actually be able to head down a more constructive path after this election cycle is over?

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Thu, 10/13/2016 - 10:11am
Sure, the ACA is great if you look at percentage of insured. But given the very recent history of premium and deductible increases, who can afford it? It would have made more sense to do what the name of the legislation says, make medical care affordable. Eliminate the restriction on negotiations in the price of drugs. Have the government set up the system for electronic medical records (which already partially exists for Medicare recipients). Put in place strong disincentives for those that abuse their bodies. Have a rational cost structure for medical procedures and medical devices. Have a rational approach to the funding and verification of drugs. Put in place strong disincentives for those providers that abuse the system and fund the investigators that track them down. In short, take a very focused look at the costs within the medical system.
Thu, 10/13/2016 - 10:44am
I worked as a nurse in health care for 30+ years and both the article and the comment by Rich make good points. We do not have a "healthcare system", we have a sickness care system. The incentives are on quantity vs. quality. The whole structure is based on doing procedures to make more money, so the "bean counters" found many ways of doing more procedures, manipulating medical care to bloat the system beyond sustainability, which is where we are today. The focus of the system needs to be on keeping people healthy and the ACA has begun that process. The problem with cost is none of the big business that has emerged around the sickness care model is willing to give up any of their profits. This is a very complex issue. I applaud Ms. Udow-Phillips for her wise perspective to improve the ACA rather than throwing out the entire legislation and starting over. I also appreciate Rich^s comments about incentives and disincentives, since the old system incentivized the keeping people coming back for more instead of making them healthy.
Michigan Observer
Thu, 10/13/2016 - 3:54pm
Bernadette says, "The problem with cost is none of the big business that has emerged around the sickness care model is willing to give up any of their profits." Perhaps she hasn't noticed, but the reason insurance companies are dropping out is that, not only aren't there any profits, there are substantial losses running in the hundreds of millions of dollars. Of course, it's always nice to have a fudge factor handy to explain manifest failure. There are three things involved in any system like health care: quantity, quality and cost. While the goal of more coverage is admirable, making a system that was providing a certain quantity of health care at a certain cost and of a certain quality, provide significantly more quantity is inevitably going to affect cost and/or quality. The crucial question to be addressed (and never was prior to the passage of ACA) is what combination of quantity, quality and cost is optimal? That is, how much additional cost (paid for with higher premiums and/or higher taxes) are we willing to pay in order to provide everybody with health insurance? Or alternatively, how much reduction in quality are we willing to tolerate in order to provide universal coverage? A Princeton economics professor was recently quoted as saying that his undergraduate economics students could have designed a better system than ACA, The architects of ACA should have copied Germany's system. They do not rely on mandates and penalties to get young, healthy people to finance medical care for older, sicker people. They simply garnishee their wages for whatever they need.
Thu, 10/13/2016 - 11:57pm
Bernadette, I agree with you the purpose should be individual health and that is not the focus of ACA. There are problems that are made so complex by trying to create the ‘grand’ solution that will be the answer to all the related problems/issues. An answer that will go down in history forever linked to a time/place/person. The ACA was written to answer all the problems/issues with that one ‘grand’ stroke and to do that it had to force all the related problems into a single problem. ACA created and ‘elephant’ of a problem. Too many times people have tried to create that one ‘grand’ answer tryiong to eat the ‘elephant’ of a problem whole. What has proven to be the most effective way to eat the ‘elephant’ is in small bites. Rather than spend all the effort to fix the ‘grand’ answer why not break it into the smallest bites possible and solve each of those and then link the solutions as appropriate. If we look at a problem as health; then break it into its parts, individual choices/practices, focusing on how to improve prevent, maintenance, innovation? Others would be working on how other parts of the problem such as access to care, geographic, financial, cultural, innovation? Still others could be allowed to work not the methods of care, innovation, delivery, broadly/narrowly applied? And still others could be working on other aspects? We do have the [per capita] most innovative/creative system in the world. We surely don’t want to discourage or even slow they dynamics of medicine and improving of health. The reality is innovation/creativity/implementation is driven by money, with out money people do have the tools to work with, they can’t survive to work, they do have the means for ideas to compete [innovation comes out of completion, not from consensus] and if the funding is controlled/doled out by a small ‘elite’ group centrally located in Washington completion dies, innovation dies, and health stagnates. ACA has become the ‘elephant’ that needs to be fixed displacing individual health being the focus of government and public efforts. Rather than continuing investing energy/time/money on making ACA be the ‘grand’ solution and slowing/stopping investments in health, let go of the ACA and focus people on the separate parts needed to achieve improved individual health.
Thu, 10/13/2016 - 10:48am
Please cut out the insurance companies all together. Want to know who the ACA is benefitting? Follow the money; insurance, and pharma. This was a republican plan put in place by democrats, so lets be clear on who "owns" this thing. It needs some revisions, but mostly, lets just go with a universal program. People, lets not be afraid of this. You thought the world was coming to an end with the ACA, and great improvements have happened, not the ceiling falling in. All people deserve to be healthy, and to have access to care. Having an insurance card goes a long way to achieving that. good legislation promotes that.
Fri, 10/14/2016 - 4:41pm
Robin, I'm not sure what plan you are looking at but if we're talking about the same ACA/Obamacare, the fact is zero Republicans voted for it. Your guys (and gals) plainly shoved exactly what they wanted through so now complaining that they didn't go far enough doesn't make much sense. Further if you can give an example of where giving (ostensibly for free) something away ever lead to higher quality and more responsive service I'd like to hear it.
Warren Cook
Thu, 10/13/2016 - 11:47am
Aren't some of the cited reductions in the uninsured statistics attributable to mandated coverages?
Kevin Grand
Thu, 10/13/2016 - 12:05pm
"But the underlying question that remains unanswered in Ryan’s plan is: Do the ACA’s results to date warrant repeal?"So, lessee here: "If you like your plan you can keep it." "If you like your doctor you can keep them." "Americans will see a cost savings of about $2,500/year." All of these 'promises' were ultimately proven to be massive lies. And then you have the state exchanges mentioned above collapsing. Insurance companies pulling out due to cost rising far greater than predictions. The illegal/unconstitutional reconciliation method in which Obamacare was jammed through Congress. Making Americans purchase a product as a condition of citizenship. The numerous exemptions and carve-outs made after the passage of Obamacare. It pays in more ways than one to support a democrat! And let's not forget the "Cadillac Tax" which Obamacare backers are loathe to admit will directly affect one of their core constituencies (Union Members). All of these point out to a troubling tactic of Obamacare backers purposefully deceiving Americans. So unless you are trying to tell readers that lies and deception are an acceptable tactic, the answer is most clearly: Yes, Obamacare can, and should be repealed!
Daniel Schifko
Sun, 10/16/2016 - 11:46am
Very well said Mr. Grand. Your logical and well structured comments should be the basis for a truth filled story in Bridge. I will not hold my breath waiting for that to happen.
Thu, 10/13/2016 - 7:31pm
There is one important point about the ACA that seems to get overlooked. We have amended the Social Security Act, Medicare, Medicaid and goodness knows how many other significant statutes frequently. These legislative modifications and fixes were driven by many things: things that the original bills got wrong; things that worked OK but could work better, and by changing conditions. No reasonable person expected the ACA to be a panacea -- no legislative act can possibly solve the problems inherent in something as complicated our health care system. There has been absolutely no interest in Congress in working to solve the ACA's problems, and the motivations for this inertia are purely political. Those who argue for repeal cannot articulate a vision for what would replace the ACA, let alone a plan to deal with the consequences of a blanket repeal.
Kevin Grand
Fri, 10/14/2016 - 1:39pm
Why is it incumbent on the federal government to solve this? The federal government has absolutely no authority whatsoever to be involved with the health care of its citizens.
Fri, 10/14/2016 - 4:51pm
So which of the 3 programs you've cited has even remotely meet its cost projections or met even remotely some semblance of actuarial and demographic soundness? Fine and dandy that the current beneficiaries love them but the math doesn't work and eventually financial gravity wins. Then what?
Thu, 10/13/2016 - 10:57pm
CAP profits would be a great place to start.