1A is part of the 2017 Aspen Ideas Festival. What's it all about?
What would happen to you tomorrow if the Affordable Care Act was repealed tonight?
We asked our listeners to share their questions, concerns and stories about health coverage under the ACA, also known as Obamacare. Plus, we discussed viable options to replacing insurance for 20 million Americans.
- Julie Rovner Senior correspondent with Kaiser Health News; author of "Health Care Policy and Politics A-Z"
- Dan Diamond Reporter with Politico and creator of "Pulse Check," a podcast that features weekly conversations about health care.
- Tom Coburn Physician; former Republican Senator from Oklahoma.
The Obama Care Repeal Efforts: Your Questions Answered
President-elect Donald Trump and Congressional Republicans have promised to repeal the Affordable Care Act as soon as possible, then spend the next two years crafting a suitable replacement.
Democratic Senator Cory Booker of New Jersey has compared this approach to pushing someone off a cliff and promising to save them before they land. And the GOP has run into some political difficulties. Regardless, committees in the House and Senate are working on repeal efforts, while a budget resolution in the Senate could start the process this week.
We asked our listeners to share their questions, concerns and stories about health coverage under the ACA, also known as Obamacare. We also talked to Julie Rovner from Kaiser Health News and Dan Diamond from Politico about what “repeal and replace” would look like for 20 million Americans.
Here are the top questions we received, and our guests’ responses:
Parth, a personal finance adviser in Texas, called to say his clients’ monthly budgets have been affected by fluctuating costs for insurance. They can’t save for vacations or retirement, he says, because their insurance costs keep going up.
Health spending has been going up for years for a long time, Rovner said. Costs under the ACA have gone up for healthy people with skimpy coverage. At the same time, others who were less healthy and who had previously had trouble getting insurance have been added to the pools, but Rovner added that the ACA has slowed general increases in costs.
John from Colorado said his insurance bills have increased, and he asked if a repeal would reduce his costs while giving him more options for insurance.
Diamond said the overall number of options for insurance has gone down for many people — in about 1,000 counties, there is only one insurance option, which can lead to higher prices due to the lack of competition. But a repeal wouldn’t necessarily change this. “If the ACA went away, would there be more competition? I’m not sure we know that,” Diamond said, noting that some elements of the ACA that would’ve attempted to increase competition were stripped from the bill before it passed.
And insurance costs aren’t only based on competition. “What mostly affects premiums is the underlying cost of healthcare,” Rovner added. “Having more competition wouldn’t lower premiums because what you’d have to do is lower that overall cost of health care.”
Joan from North Carolina asked about closing the donut hole in prescription drug plans.
“Even if with my insurance coverage, I can find myself spending $1,000 or more a month,” she said. This donut hole was created by a 2003 measure that added prescription drugs to Medicare coverage, but with a gap in coverage. People who spent relatively little on prescriptions were covered, as were people who spent the most, but those in between were not. This will be phased out by 2020.
“It’s unclear whether Republicans would try to take that away in a repeal,” Rovner said. To which Diamond added that, partially due to lobbying from Big Pharma, the ACA as written does not do much to lower the actual cost to patients of prescription drugs.
Tim from Arkansas called to say that if the ACA went away, his sons wouldn’t have to pay a fee for not having insurance. And that seemed fine for him, since he didn’t think the government should be handling health insurance anyway.
“Most people have insurance through their job or through Medicare or Medicaid,” Rovner said. For them, the fact that the ACA penalizes people without insurance isn’t a concern. Last year, about 8 million people were fined. The fees totaled about $3 billion.
Those penalties may not have been an accident. Diamond cited a study from Kaiser Family Foundation to say that for about 7 million Americans, the penalty is less than the actual cost of buying insurance, and indeed, some callers to 1A told us this was the case for them.
But this creates a conundrum. “There’s a consensus people should have health insurance,” Rovner said. Accidents could always happen. “You’re risking your health down the line, but in the short term, maybe you’re saving money,” Diamond added.
But by forgoing insurance, you’re not helping others save money. Healthy people avoiding buying insurance can raise premiums on everyone else, since it decreases the overall size and health of the insurance pool.
Diamond said perhaps if Hillary Clinton had won the election, he and Rovner might be on 1A to discuss the addition of a public option in an attempt to increase competition among private insurers.
Marjorie from Virginia said the ACA has covered her mental health care for years. Shelley on Twitter asked about mental health insurance under the ACA, too.
Rovner said an ACA repeal likely would not eliminate many mental health coverage plans. That’s because the 2008 Mental Health Parity Act required insurance plans that already covered mental health care to cover it to the same degree as other care. Rovner said the ACA added a provision that pretty much all plans have to cover mental health. That, combined with the 2008 act, means that most plans cover mental health, and cover it as much as anything else. An ACA repeal would not change the Mental Health Parity Act.
Several callers said the ACA gave them the freedom to leave their jobs and go freelance, or it made it possible for them to stay working jobs that didn’t provide insurance. They wondered whether this had a positive effect on the economy.
“One of the myths at the beginning was this would be the job-killing healthcare law,” Obama has said, noting that instead the private sector has gained “more than 15 million jobs, healthcare more than 2 million.”
“In the last days of the [Obama] administration, they’re making this case coast-to-coast,” Diamond said. “If you’re trying to make the argument that this a job killer, there’s very little evidence.”
Are any congressional efforts about changing the insurance industry?
Yes there is talk of reform, to a degree, Rovner said. But, since the government doesn’t control the healthcare and insurance industry, “most of this is being done through the Medicare program,” she said. It’s a form of leading by example. The way Medicare pays doctors, hospitals, and nursing homes have “leaked over into the private sector,” Rovner added. And the most notable change is that the ACA focuses on paying for results and treatments, rather than patient inputs.
“It’s slow, it’s hard to measure, not everything seems to work, but at least there was effort in the law,” she said.
Bill asked on Twitter why the law focuses on states running health insurance marketplaces. That wasn’t originally the case, Rovner said.
“When the Democrats were pushing the Affordable Care Act, they were trying to make it as attractive to Republicans as they possibly could,” she said. That meant giving states the options to set up the insurance exchanges. But only about a dozen states have actually done that. The rest use exchanges run by the federal government through healthcare.gov, which Diamond says is basically “a de facto national exchange.”
Annabelle, who called us from Maryland, is among many people in their early 20s who are on their parents’ health plans due to the ACA. Trump has promised to keep this.
But while this is a popular part of the law, it isn’t necessarily the best business decision. “Allowing adult children to stay on their parents’ health plans has been kind of a mixed blessing” Rovner said. “If those 22- to 26-year-olds had been in the market, it would’ve brought premiums down.”
Trump has also indicated that he would like to keep the facet of the ACA that prevents insurance companies from denying plans to customers with pre-existing conditions. Basically, the guests agreed that if this regulation stands, so must the mandate that everyone have insurance, otherwise premiums would skyrocket.
Fran and Audrey are small business owners. They separately called to say the ACA has raised rates for the policies they use to cover their employees.
Rovner said if Clinton had won the presidential election, and the focus weren’t on repealing the ACA, but on modifying it, then “what to do about small business and their coverage would’ve been at the top of the agenda.”
Rovner added that regulations meant to help small businesses have been more cumbersome than helpful.
“Basically, small business hasn’t been helped much by the Affordable Care Act,” she said. “I don’t think in many cases they’re particularly worse of than they were before the law. But they were in not great shape before the law and they are in not great shape now.”
Katrina on Twitter said her health plan is thirty dollars a month, and wondered if any other health plans for women could be comparable.
“It’s unclear,” Rovner said. Currently, however, regulation requires that contraception be covered under the ACA. But, Rovner notes, that could be repealed by congressional Republicans who have long said they want to cut funding to Planned Parenthood.
“We’ll have to see how it plays out,” she said.
Facebook Live With The Experts
After the show, Julie Rovner and Dan Diamond took a few more questions from listeners on Facebook Live.
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