affordable care act

Summary

With the election of Donald Trump and the appointment of Tom Price to head up the Department of Health and Human Services, the Affordable Care Act (ACA) is in trouble. President Trump has said he will repeal and replace. Price has voted to dismantle the ACA over and over again.

The ACA works to address the increasing costs of health insurance and the high number of uninsured Americans. It’s had success on both these fronts. Unfortunately, the ACA is likely going to be repealed. We should, until the repeal goes through, do our best to argue the merits of reform rather than repeal, point out the ACA's successes, and show how much less complex it would be to fix and improve than repeal and replace. We should also be ready to point out where Republican alternatives fall short and how Trump himself has promised to replace immediately and that repeal and wait would cause untold hardship for many people who would lose their insurance.

Background 

• Congress passed the Affordable Care Act on March 23rd, 2010.
• It was created to make health insurance more affordable and reduce the number of uninsured Americans.
• Significant details of the ACA include the following:
  • the individual mandate to get health insurance
  • the mandate for employers to offer insurance if they have 50 or more employees
  • expanding Medicaid
  • preventing pre-existing conditions exclusions
  • creating health insurance exchanges for people to review private plans available to them, thereby increasing competition among health insurance providers
  • tax credits and subsidies for people who can’t afford coverage
• The ACA has been successful in reducing the number of uninsured Americans as well as slowing the rate of increasing premiums.
• However, premiums have been rising and insurers have been dropping out of the system largely due to less than anticipated participation. This is the major criticism of the ACA.

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the best defenses

Response 1: While the average healthcare cost per family has increased since the ACA passed, it has increased at a slower rate than in previous years. Though showing the precise effect of the ACA is difficult, we can confidently say that if insurance premiums and healthcare costs increased at the rate they were increasing before the ACA passed, the average family would be spending thousands more for health insurance now. Considering this, repealing the ACA (especially without a replacement) would likely increase costs even more.

Response 2: Many of these “ACA horror stories” have been debunked.

Response 3: Health insurance, even mediocre health insurance, is better than no health insurance. Since the ACA passed, the number of uninsured Americans has dropped significantly.

• In 2015, for the first time in our nation’s history, the percentage of uninsured Americans dropped below 10%. This decrease in uninsured Americans is due to the ACA. In 2010 the number was 16%. 2013 it was 14.4%. 2014 it was 11.5%. As the ACA has been enacted and implemented, the number of uninsured Americans has decreased by nearly half. Around twenty-one million more people now have access to affordable healthcare.
• Due to this increased coverage, many people thank the ACA for saving their lives.

Response 4: High premiums under the ACA are certainly a problem (current projections are that premiums will increase by 22% in 2017), but it's cheaper and more efficient to fix and improve the ACA rather than repeal and replace it.

• Increasing subsidies for people signing up for insurance would reduce households' costs.
• Subsidizing insurers to enter the exchange would increase competition, which should reduce premiums if a monopoly can be prevented.
• Raising the income limits at which people can qualify for subsidies would combat the high costs of premiums for the middle class.  
• There are many more strategies for reforming rather than repealing.

Response 5: Tom Price’s EPFA plan doesn’t fix the problem of high premiums.

• One of the reasons premiums have gone up is that not enough young, healthy people have signed up to subsidize premiums for older, sicker people. The EPFA doesn’t mandate that younger, healthier people join, yet it claims to still provide health insurance for older, sicker people. This will probably lead to even higher costs for households than the ACA.
• The EPFA’s tax credits are based on age not income, which leaves low income earners, the people who previously struggled to afford health insurance, without economic support. The tax credits it offers aren’t near enough to solve this issue.

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Response 1: The ACA wasn’t a government takeover of health insurance.

• While the ACA includes new regulations and subsidies for existing health insurance plans, it doesn’t create any new government-run health insurance or healthcare.
  • Obama originally proposed a public option which would be a government-run health insurance plan that could compete with private health insurance plans, but that was removed from the bill before Congress passed it.
  • The ACA doesn’t even come close to a single payer system in which either the government would run healthcare facilities (as in the UK), or would pay for the healthcare of its citizens from private doctors (as in Canada).  
• Government-run health insurance plans do exist (Medicaid and Medicare, for example) but they existed before the ACA. The ACA mostly doesn’t affect these programs, except for expanding Medicaid.
  • Medicaid is a government-run health insurance option for low-income earners. In 2014, the ACA changed its enrollment qualifications to include Americans making below 133% percent of the poverty line. This expanded the pool of potential Medicaid recipients.
    • Medicaid is still exclusively for individuals who can’t afford private health insurance. Expanding it is, in no way, a government takeover of private insurance.

Response 2: Medicare (a government-run health insurance program for the elderly) is less expensive and more efficient than private health insurance.

Response 3: Private health insurance plans are just as complex, if not more so, than the existing government-run programs of Medicaid and Medicare.

• If you are complaining about the complexity of plans offered through the ACA exchanges, remember, those are private health insurance plans. Private plans are needlessly complex, with or without the ACA.
• Patients, hospital employees, and even doctors are regularly confused about what procedures are covered under a patient’s plan. One in three Americans will receive large bills from their insurance companies for services they believed would be covered and wouldn’t have had performed if they knew they’d be charged.
• Private plans cause patients so much confusion, that they end up paying more for health insurance while their private health insurance companies make more money as a result. Private insurance companies, therefore, have a profit motive to make their plans complex.
• No plan is simpler than a single payer, government-run plan.
• Private health insurance plans in the US are so complex that they cost billions of dollars just in paperwork alone.
• There's a strong argument that the ACA's reliance on private insurance companies is the reason for complexity and high costs in the first place, indicating that private insurance plans, and not the ACA itself, are to blame for our health insurance mess.

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Response 1: It’s true that Obama said under the ACA Americans could keep their plans and that wasn’t true. However, the conservative attack on Obama is misleading.

• Repealing and replacing the ACA won’t get people their old plans back. It will just require them to get another plan with a whole new complex set of rules.
• Many people who lost their health insurance plans under the ACA qualify for similar, and possibly better, health insurance plans through the ACA.

Response 2: That may be true but many more Americans have health insurance for the first time because of the ACA.

• In 2015, for the first time in our nation’s history, the number of uninsured Americans dropped below 10%. This decrease in uninsured Americans is due to the ACA. In 2010 the number was 16%. 2013 it was 14.4%. 2014 it was 11.5%. As the ACA has been enacted and implemented, the number of uninsured Americans has decreased by nearly half. Around twenty-one million more people now have access to affordable healthcare. Even the highest estimates of canceled insurance policies don’t come close to that number. Also, many people whose plans were cancelled can get new plans, often for less money.

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Response 1: Americans are already forced to pay for others' health insurance through their taxes.

• Since 1986, hospitals can no longer turn people away because of a lack of insurance due to the Emergency Medical Treatment and Labor Act (EMTALA). This federal law passed with strong bipartisan support because of an alarmingly high number of cases of uninsured people being turned away from private hospitals and dying or losing loved ones on their way to public medical facilities.
• However EMTALA was never funded, and now medical care for the uninsured is paid for by your taxes or by hospitals, who in turn increase costs for you and your insurance to cover for the amount they spend on the uninsured.
• In 2013, before the ACA went into effect, medical bills were the largest cause of personal bankruptcies in the US. When a person declares bankruptcy, their creditors receive a lot less than what they’re owed. In order to account for this loss, companies raise the prices of their service. Consequently, we're all paying more for health care due, in part, to the large number of medical cost related bankruptcies.
  • The ACA doesn’t do much to change this as many of the people who declare bankruptcy are insured. However, it’s another example of how we pay already for other people's healthcare.

Response 2: Since we already pay, why not pay less?

• The mandate decreases our costs for health insurance, because the premiums that younger, healthier patients pay actually subsidize the cost of care for older, sicker customers.

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Response 1: Price’s plan, the Empowering Patients First Act (EPFA) gets rid of the successful parts of the ACA without addressing the ACA’s flaws:

• The ACA has been most successful in getting Americans insured. In 2015, for the first time in our nation’s history, the number of uninsured Americans dropped below 10%. Before the ACA, 16% of Americans were uninsured because they couldn’t afford insurance. The ACA has successfully gotten many of these Americans health insurance by expanding Medicaid for low-income earners and offering financial support to those who don’t qualify for Medicaid. The EPFA doesn’t provide help for lower-income people to get insured.  
  • The EPFA does nothing to replace the federally-funded Medicaid expansion. If the EPFA replaces the ACA, then 14 million Americans will lose coverage immediately.
  • The EPFA, like the ACA, uses tax credits to subsidize insurance costs. However, the EPFA’s tax credits are based on age not income, which isn’t helpful to many of the low income earners who just got coverage.
• Before the ACA, Americans with pre-existing conditions were regularly denied affordable coverage. The ACA addressed this by forbidding insurance plans from including pre-existing conditions exclusions. The EPFA weakens protections for Americans with pre-existing conditions.
  • Under the EPFA, only patients who have been continuously insured for the past 18 months would would be protected from price hikes or denial of coverage. That means if you have just one month of no coverage in the last 18 (maybe you were in between jobs and weren’t covered for a month), you would not be protected under the EPFA.
    • People with pre-existing conditions, struggling to afford health insurance due to a high premium, are likely to have at least one month of no coverage. They would, under the EPFA, then have an even more difficult time getting covered for 18 months as now they aren’t protected from price hikes and denials of coverage.
      • The EPFA’s 18-month policy isn’t nearly as helpful for people with pre-existing conditions (especially lower income people), who can easily fall into a chronically uninsured state.
• The EPFA’s solution to dealing with uninsured people with pre-existing conditions is to establish state-based, high-risk pools to help pay for high premiums. However, these high-risk pools are much too small to be that helpful. In Price’s plan, the risk pools are even smaller than in other Republican plans.
  • Price’s $3 billion figure is significantly less money than other proposed replacements to the ACA. Paul Ryan’s plan would put aside $25 billion over a decade for the same purpose. Price’s plan endangers patients with pre-existing conditions far more than plans from his Republican colleagues.
  • Risk pools have failed in the past due to being underfunded. They would likely fail again considering how underfunded Price’s risk pools would be.
• The major problem with the ACA is rising premiums. The EPFA does nothing to address rising premiums and instead removes the ACA mandate designed to keep premiums down.
  • When the ACA was created, the mandate was supposed to keep premiums down. The strategy was that healthier people, mandated to buy health insurance, would offset the cost insurance companies had to pay to insure sicker, older people. However, the mandate hasn’t been as effective as intended (fewer younger, healthier people than anticipated have signed up for health insurance) and insurance companies have hiked premiums to cover costs.
  • The EPFA removes the mandate, removing the main strategy the ACA had for combatting higher premiums.

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Warnings

A lot of analysis has been done on the ACA, EPFA, and healthcare in America in general with different conclusions. There are plenty of partisan numbers that either side can use. Every projection about which approach would insure more people or save the government more money is technically speculation. If your audience has done research on this subject, expect them to have different numbers. Be ready to support your numbers and/or make an emotional argument about the health of the uninsured.

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