As the race for the White House tightens, a number of stories over the past week have cast a bright light on how the election outcome could shape future health care policy. On the one hand, the contours of the next wave of health reform that would build on the Affordable Care Act’s foundation are emerging. On the other hand, Medicaid waiver proposals from several states plus debates on the future direction of health reform that are swirling within the political right-wing paint a disquieting picture of where health policy might go should "anti-ACA" candidates prevail.
New data from the Census Bureau underscores both the success of the ACA and the need for additional action. In particular, the Census data corroborate the recent findings from the Centers for Disease Control that thanks to the ACA, the proportion of the U.S. population lacking health insurance is smaller than it has ever been in history. At the same time, high out-of-pocket spending is spiking and health costs still drive too many households into poverty.
And it now seems clear that no county will go without any available insurer and some carriers who threatened to pull out may be having a change of heart. However, in the long run it will be impossible to hold insurers accountable for either premiums or other policies affecting coverage and cost (such as benefit design) if regulators are constantly worrying about market exit.
What these recent stories illustrate is that despite the great progress we have seen, more needs to be done to ensure quality affordable coverage is available to all. We are seeing steps to address this "unfinished business" at both the state and national level.
Consider two recent developments in California. The state recently passed legislation that would extend protection to consumers against surprise out-of-network bills, a growing problem in the context of the narrow networks that are becoming commonplace on the ACA marketplaces and beyond. They are also moving to fill a gap created in the ACA by the ban prohibiting undocumented immigrants from obtaining Marketplace coverage. This was ill-considered policy adopted for reasons of "optics," but since undocumented immigrants are not eligible for premium tax credits (a whole different story) there is nothing gained from excluding them from marketplace coverage.
On the federal level we are seeing a renewed push for a public option that would enhance choice and reduce premiums on the marketplaces. Members of Congress are also taking aim at price gouging by the drug industry with new bipartisan calls for increased scrutiny of excessive price increases. While these federal initiatives face tough sledding – even if the election outcome is favorable to health reform – the very fact there is a renewed push for progressive reform is a step in the right direction.
On the other hand, we see a starkly different vision in the Medicaid waiver proposals from Ohio (recently rejected) and Kentucky (still pending). What would states do with the kind of "flexibility" that is promised in the House Republican "Better Way" ACA repeal/replace proposal? Apparently, at least some, if not most would create new barriers to coverage -- including higher premiums, higher cost-sharing and arbitrary coverage lockouts -- that would force many back into the ranks of the uninsured and undermine financial protection for those who do manage to hold on to coverage. These proposals are likely only the tip of the iceberg of what we would see since they are being put forward in the context of the current state entitlement to federal matching funds -- a commitment that Congressman Ryan and the House leadership are intent on eliminating.
The agenda embodied in the so-called “Better Way” proposal is deeply unpopular with the American people. Even in Speaker Ryan’s home district, consumers seem more interested in expanding coverage while providers worry about the disruption and spiking uncompensated care costs that would accompany a rollback of the ACA.
But as problematic as the House proposals are, the reality could be even worse. Observers on the "conventional right" are already warning against what they see as a nascent effort by the far-right to enact "repeal" without "replace.” While such an approach might seem politically irrational, it is these very same irrational forces that forced a government shutdown and the resignation of Speaker Boehner. While political backlash would likely follow from a coverage rollback and the ensuing financial disruption, this is cold comfort for the millions who would lose coverage -- especially since it would take years to reassemble the political alignment that was necessary to pass the ACA (not to mention Medicaid) in the first place.
So we are in a strange moment. Even as the evidence mounts that the ACA has improved access to care and financial security for millions, these gains hang by a slim margin if current polls are an accurate predictor of the electorate on November 8. All elections have consequences, but some have more than others. For health care, it is hard to imagine higher stakes.