This article originally appeared in Capital Commentary, a weekly current affairs publication of the Center for Public Justice.
This is the second installment in a two-part series. Click here for part one.
Preliminary indications are that the Affordable Care Act (ACA) made substantial progress in reducing the number of Americans without health coverage. The Robert Wood Johnson Foundation reports that in early March (before the final enrollment surge), uninsured adults declined by 5.4 million, bringing down the rate from 17.5 to 15.2 percent. But what are the law’s prospects from 2014 into the next presidential administration in 2017?
Three paths are possible: the current road, the hopeful road, and the repeal road.
The current road is the most likely scenario, no matter the 2014 election outcome. From the Center for Public Justice’s good governance and public justice perspective, it’s a road of potholes and dead ends. ACA implementation features strident political stalemate, with Republicans and Democrats maneuvering around (and sometimes creating) potholes for partisan advantage.
Continued Republican control of the House (and perhaps the Senate) will mean attempts to starve the law of funds for implementation. Yet no matter the 2015 balance of power in the House and Senate, President Obama holds the veto pen until January 2017, guaranteeing continued implementation despite political obstacles.
The hopeful road is a path where partisans on both sides realize that good governance and the common good trump politics. A recent statement by the Catholic Health Association (CHA) describes this hope:
We have always known that the Affordable Care Act, like other laws, is not perfect, but it is a
real start on the road to health security for millions of people. It is a first step in refocusing our delivery system in a way that serves our country and its people so much better. . . . We have much to do to improve and expand the impact of this law but we have seen the tangible good it has done already and will be there to share our concerns and suggestions as our nation
builds on this achievement.
The unique parliamentary maneuvering that created the ACA generated errors that normally would have been reconciled in the legislative process, had that process not been broken. For example, a drafting error creates uncertainty about subsidies on the federal marketplaces. There also are problems with the standards for employer-based insurance that determine whether an employee may obtain family insurance on the marketplaces.
Beyond technical adjustments, there are sound arguments to allow more flexible enrollment options; to revise the design of the employer mandate, especially as it applies to medium-sized businesses and part-time employees; to ease employer reporting requirements; and to allow insurance companies to design more affordable policy options.
Most Democrats are open to making typical legislative adjustments to the ACA as problems are discovered. Republicans, however, are reluctant to engage in this exercise. Their price for making minor adjustments is to open the law to major changes that Democrats cannot countenance. The short-run thus offers only scant optimism that Congress will take the hopeful, good governance road.
The repeal road’s prospects depend entirely on a resounding Republican victory in the 2014 and 2016 elections, a not impossible result. Because CPJ principles affirm guaranteed health insurance as essential to poverty alleviation and full citizenship, the repeal road traverses difficult mountain passes with sheer drops on each side. This road promises a 10 million person reduction in uninsurance at best, which is half to one-third the ACA prospect.
Mainstream Republican proposals, recognizing the popularity of parts of the law, retain many ACA features. Unlikely to be changed are elimination of lifetime caps, preventive care coverage, maximum deductibles, and forbidding pre-existing condition exclusions. Ideologically, Republicans do not favor them, but politically they cannot take away popular benefits.
Republican plans eliminate the law’s individual and employer insurance purchase mandates and Medicaid expansion. A prominent proposal is expansion of Health Savings Accounts (individual tax-free savings plans used to cover medical expenses) and high-deductible, catastrophic insurance plans.
Republican proposals include refundable tax credits to assist low-income persons to purchase insurance (an ACA feature), but these would be available to fewer persons and worth less than in ACA (and with stiffer penalties for failing to buy insurance). Small businesses would be encouraged to join “association health plans” for better rates, and plans would cross state lines, bypassing state insurance regulations and benefit mandates. Republicans also favor malpractice reform to hold down cost increases.
Other Republican reform proposals eliminate or reduce decades-old tax benefits that encourage employers to offer employee insurance. They allow insurance companies once again to deny coverage for pre-existing conditions (if persons do not buy insurance at their first opportunity) and to charge higher premiums for older and sicker persons. They create state-based high-risk insurance pools for persons unable to afford commercial insurance.
Major progressive alternatives, especially “single-payer,” have scant chance of passage without continued ACA implementation failures, coupled with election of a Democratic president and an overwhelmingly Democratic Congress in 2016, a highly unlikely combination. If the analysis here is accurate, then we should be praying fervently that political leaders find the wisdom and courage to take the hopeful road.
- Clarke E. Cochran is Professor Emeritus, Political Science at Texas Tech University and former Vice President of Mission Integration at Covenant Health in Lubbock, Texas.