The Patient Protection and Affordable Care Act passed on March 23, 2010. The underlying philosophy was to make coverage available and affordable to all Americans. At the time, there were approximately 45 million uninsured individuals in the US. Today, that number is about 28 million. The tax credits or subsidies have helped many to afford health insurance coverage. The expansion of Medicaid in Pennsylvania has also allowed more to find the coverage they need. Yet health insurance rates have been on a steady increase for both employers purchasing health insurance coverage and for individuals. The ACA has imposed a myriad of regulations on health insurance carriers and the Federally Facilitated Marketplace in Pennsylvania; also known as the Exchange.
President Trump campaigned on repeal and replacement of the ACA, but that has not yet come to fruition. The House passed the AHCA, American Health Care Act. The Senate created its own bill, BCRA, the Better Care Reconciliation Act. Versions of each, with necessary updates, continue to be discussed among the Legislators. There is a bipartisan group of 43 in the House, the Problem Solvers Caucus. They want to discuss the reforms needed within the ACA. Their main concerns are: to continue the Cost Sharing Reduction subsidies for individuals below 250% of the Federal Poverty Limit; a dedicated stability fund to help states to keep costs down (reinsurance); exempt “small” businesses from the employer mandate by raising the definition to those businesses with more than 500 employees; repeal of the medical device tax, a 2.3% tax on items like pacemakers and knee replacements; and the ability to sell insurance across state lines.
There are a few other ideas that have continued to garner support as a way to fix the ACA. One of those is to increase the rating ratio from 3:1 to 5:1. Currently, a 64-year-old cannot be charged more than three times the 21-year-old. Along with this comes the suggestion to give more generous subsidies to older Americans. There are discussions of price controls on prescriptions drugs, allowing Medicare to negotiate pricing, and reviewing how other countries control the prices of pharmaceuticals. The use of bundled payments for care versus episodic payments has helped to reduce costs. A knee replacement, as an example, would be one payment to the Hospital and another to the Doctor for pre-operation, operation, and post-operative care. Antitrust reform to control the hospital mergers; the consolidation of services can be positive, but the elimination of competition often drives prices higher. Tort reform has always been debated as a way to reduce costs. The abuse of malpractice suits means that hospitals and doctors over-treat and over-test.
The idea of “Medicare for All” was a campaign highlight for the Democrats in the last presidential election process. There has been talk about reducing the eligibility to age 55, instead of 65, to enroll in Medicare. Of course, this would require some changes in the type of plans offered. Those 55 and older and still actively at work have demands for health care that are different from those who are retired.
There is not much language available now to show how we would transition from our current system to a “Medicare for All” system. Private insurance companies have no role in the Sanders version of single-payer, other than providing supplemental insurance. The biggest concern is how to pay for it. Vermont studied the viability of a single-payer Exchange for their state, before scrapping the idea, in part, because of cost. It was on the ballot for Colorado voters, who turned it down. California continues to debate the idea of a state single-payer Marketplace. Financing has been a stumbling block. Rep. Conyers has over 100 backers in the House for his version of a single-payer legislation. It will be a tough road ahead with a Republican-controlled House, Senate, and President.
A recent Pew Research Center poll shows that overall, 33% of Americans believe health care should be a single-payer setup. The poll also found that roughly 60% of Americans believe the government is responsible for making sure all Americans have health insurance. Where do you stand on the issue? Use your vote in the upcoming 2018 elections to make your voice heard.
