Saving the Affordable Care Act

In what is called President Obama’ s most important legislation, the Affordable Care Act, has been under constant fire. The House voted 54 times to end it. The GOP shut down the government trying to kill it. Recent polls show that the majority of  the American people are against it. It is cited as part of the reason the Democrats lost control of the House in the 2010 election and then of the Senate in 2014.

Why?

The Affordable Care Act was developed to curb the abuses of the medical insurance industry. Individuals needing health care coverage that was not available to them through their employer  or through a federal program like Medicare or Medicaid (Medical in California), had to apply to the healthcare insurance companies operating in their area. People found to have had pre-existing medical conditions were faced with very high, almost unaffordable policy options. Companies also asked questions about behavior such as whether someone smoked cigarettes or marijuana, whether one drank and how much and about any previous medical conditions even if they were no longer a problem. The companies would then raise their rates accordingly.

Insurance companies also had caps limiting the amount of claims they would accept. If the patient cost them too much, they could discontinue their coverage.

As many as 50 million were thought to be without any medical coverage. When their illness became too much to ignore, many would wind up in the emergency room of their local hospital making the cost of their treatment even greater. Some could not pay for their treatment theoretically making everyone pay a little more to make up for the loss.

The Affordable Care Act (ACA) came up with a solution. Let individuals without insurance sign up for it through a health exchange in their state. The exchange would let all the health care carriers bid to get the business. This would make their rates more competitive. The companies could not ask about pre-existing medical conditions or lifestyle questions. They had to accept all applicants. But in order for this to work for the insurers, everyone had to get coverage. To ensure that everyone got coverage, fines would be imposed on those who elected to not sign up. Hopefully, with everyone getting coverage, there would be enough healthy applicants to make up for the unhealthy ones who would be sure to sign up.

In order to ensure that everyone could afford coverage, the government promised to give tax credits to those with insufficient means. Those with almost no money would be transferred to the Medicaid program where they would get coverage for free.

We were told that those who do not sign up are being irresponsible causing the rest of us to pay for their medical care, if it is ever needed.

But many people objected. Why should the young and healthy, who might not need medical coverage subsidize the unhealthy? Why should people be forced to buy insurance they didn’t need? And why are some people getting tax credits? Will this be like the Earned Income Credit which has a fraud rate of about $11 billion a year? And does the government have the right to fine or tax the public for non-compliance?

Now that the GOP controls both chambers, it is likely they will try again to force the President to end the ACA.

I think that I have come up with a way to make everyone happy.

First, keep all the favorable parts of ACA including allowing children under 26 to be on their parents’ plan (proving what I have been saying that now anyone under 26 in still a child - that 26 is the new 21 and 18), having no caps, and having state exchanges to bring all the available companies in a competition for this once captive audience. The mandate that businesses of a certain size must offer health insurance to its employees who work at least a certain number of hours a week should remain as would federal coverage still be available to those who cannot afford coverage at all.

The individual mandate should be dropped. People should be able to keep whatever coverage they currently have and those without any coverage do not need to buy it. In return, the private insurers bidding in the state exchanges can reject any applicant with serious, long term and well-documented medical conditions like cancer, heart disease, kidney failure, liver disease, pancreatitis, and AIDS. They could not consider past injuries, alcohol or tobacco use, etc. - just the agreed upon serious pre-existing conditions. Those rejected for serious conditions would be immediately transferred to the federal program, just like those with insufficient income are, except these people would have the same share of cost as they would have through the exchange if they were healthy.

Since private carriers would have no new policies with serious medical pre-existing conditions, they would not need everyone to enroll to make money. And since people would buy insurance only if they chose to and since there would be no federal subsidy through tax credits, the insurers would have to lower their rates to be competitive. Income would not be an issue unless the person were close to indigent and therefore also eligible to federal medical coverage, but with no deductible. There would be no fines for non-compliance because compliance would be voluntary.

But what about the argument that those who choose to go without insurance are being irresponsible? Is a person who keeps himself healthy and never needs medical services irresponsible? If he does need to see a doctor, he will have to pay for it. How is that irresponsible? On the other hand, if a person abuses his body with excessive food, alcohol, tobacco and/or drugs, but has coverage and makes use of it regularly, is he responsible? Does he not cost the ratepayer and the taxpayer more than the person who takes care of himself and needs little medical attention?

I think that with these changes, most of the objections to ACA will disappear and the vast majority of our people will embrace it. Even Republicans.