Tag Archives: Obamacare

A Retrospective on Healthcare, and Where Do We Go from Here?


800px-Capitol_Building_Full_ViewRegular readers of this blog know that I am not a fan of Obamacare. It is overly prescriptive, too costly, and has been poorly implemented. Readers also know that I have said from the beginning that it needed corrections.

I have never been hung up on whether Congress called it repeal or replacement, as long as our healthcare system was fixed . . . or at least improved.

In November 2013, I recommended the following reforms:

  • Put all forms of health insurance (employer-based and other) on an equal footing
  • Permit a wide variety of insurance plans, from catastrophic plans to high-deductible plans to those with varying levels of coverage and exclusions
  • Provide direct subsidies to the poor and seriously ill so they can purchase healthcare coverage on the open market
  • Repeal the individual and employer mandates

I said,

“In short, the type of healthcare insurance to buy should become a decision that individuals make, not the government. Insurers should be free to design policies that consumers want, and to price them at levels that are profitable. We should abandon the notion that the federal government knows what one-size-fits-all insurance programs are ‘best’ for Americans.”

The Republican bill that Congress could not pass, the American Health Care Act (AHCA), was far from perfect in addressing my concerns, but it addressed some of them. I thought it was better than the Obamacare statute as it exists now. Frankly, the fact that no one liked it made me think the AHCA was as good as we were going to get.

But it went nowhere. Apparently, the split between the ultra-conservative and the establishment branches of the Republican Party is wider than 218 votes, and no bill could bridge the gap.

As the Wall Street Journal stated on March 24, 2017, in The ObamaCare Republicans:

“[The AHCA] worked off the reality that the U.S. health system has changed under ObamaCare and thus an orderly transition is necessary to get to a free-market system without throwing millions off insurance. The GOP also is a center-right coalition with competing views and priorities. The bill had flaws but was the largest entitlement reform and spending reduction in recent decades.”

So, given that Obamacare needs reform, where do we go from here?

I don’t know.

HHS sealHHS Secretary Tom Price can work on regulatory reforms, but only within the confines of the Obamacare language. Some of the most pressing issues are part of the statute and cannot be changed (though the Obama administration delayed some of them, or gave exceptions, and perhaps the Trump administration will do the same). Some of these issues include:

  • The tax on medical devices
  • The details of the mandated benefits (“essential health benefits”)
  • The Cadillac tax on employer healthcare plans, which, if implemented, will suck in more and more employers over time as the cost of mandated benefits rises

The fundamental problem with healthcare in the U.S. is that most Americans have not paid the full cost of their care since the 1930s, when employers began offering medical insurance as a benefit. As with all consumer goods and services, Americans want high quality, high quantity, and low prices on healthcare. Any economist can tell you that you can’t have all three—two of the three is the best you can hope for. The ideal system is often a compromise on all three. When healthcare prices are artificially lowered for the consumer, they make irrational decisions on quantity and quality—overusing the system and expecting Cadillac care for Fiat prices.

In my opinion, our healthcare system will not be fixed until employer-based plans are no longer the preferred way of covering the cost. Don’t get me wrong, many employers do an excellent job of managing their healthcare benefit plans. But the distortion in the market caused by these plans is increasing and is only made worse by Obamacare.

The different tax treatment of employer-based premiums and premiums for individual plans is unfair. The proposed AHCA would have helped in that regard, though it wouldn’t have fixed the problem entirely.

As the Wall Street Journal editorial said:

“An ideal free health-care market is never going to happen in one sweeping bill. The American political system is designed to make change slow and difficult, thank goodness. Republicans have to build their vision piece by piece, carefully gauging how to sustain their policy gains politically—the same way Democrats expanded the welfare and entitlement state over the last century.”

I suppose that’s where we go from here.

What do you think?

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Power, Negotiation, and the Affordable Care Act: A Look Toward the Future


I didn’t expect to be writing about the King v. Burwell decision today. I didn’t expect the Supreme Court to publish its decision until today. But we got it last Wednesday.

I’m not surprised by the decision. As I wrote after the oral argument in March,

“My prediction is that we will either have a 6-3 vote to uphold the IRS interpretation, or we will have a 5-4 decision against the government. I think the Chief Justice will want to be in the majority on this case, so he can at least assign the opinion, and quite likely keep it for himself. That way, he can shape the future of the Affordable Care Act, as he did in National Federation of Independent Business v. Sebelius.”

The first of my scenarios came true: Chief Justice Roberts was in the majority and did keep the opinion for himself. He admitted that the ACA “contains more than a few examples of inartful drafting,” but decided that undoing the subsidies in states using the federal exchange would negate Congress’s overall intent. Congress intended to prevent “death spirals” in the insurance market, and prohibiting subsidies would vastly increase the likelihood of such destabilization in the insurance market.

Once again, Chief Justice Roberts kept the Affordable Care Act from collapsing, thus supporting a poorly written statute the Democrats crammed down the nation’s throat in 2010.

So, where do we go from here? As I wrote just a few weeks ago, the ACA needs fixing for a variety of reasons. While I would prefer to see Congress start from scratch with a market-based approach to healthcare—an approach not based on employer subsidies—the likelihood is that we cannot get there from here. And probably should not.

I recently attended a mediation training program that talked about negotiation power. The presenter made several points about power:

  • Power is relative—it depends on the specific parties to the negotiation and their circumstances.
  • Power is not static—it changes as time passes and the parties change.
  • And the exercise of power has both benefits and costs. The benefit, of course, is that the parties that exercise their power are more likely to get what they want. But at the same time, each exercise of power changes the dynamics of the situation and often increases the resistance of the other party, which can make future concessions more difficult.

This is exactly what has happened in the Obamacare debate. Because the act passed solely by exercise of Democratic power, Republicans became entrenched in pursuing its defeat. They had not been a part of the negotiations. They had been steamrolled, and they didn’t—and still don’t—like it. The temptation will be for Republicans to run the steamroller back over the Democrats, if they get the opportunity.

But what we need is a candid, bipartisan review of the problems with Obamacare, starting with

  • The tax on medical devices
  • The panoply of mandated benefits that make little or no sense (e.g., requiring nuns to cover birth control) and increase costs
  • The fiction of charging older people no more than three times what younger people are charged when older citizens need far more healthcare than the young
  • The Cadillac tax on employers that provide strong healthcare plans
  • The definition of “full-time employee” that employers must cover under the law as someone who works 30 hours per week

It has been said that healthcare reform is based on a “three-legged stool” approach of (1) requiring insurers to treat everyone the same regardless of preexisting conditions, (2) mandating that everyone buy insurance, and (3) subsidizing insurance to make it affordable. Even if we keep these legs (and the individual mandate remains highly unpopular), how can we reduce the onerous and costly impacts of the reforms?

  • Fewer mandated benefits.
  • Allowing people to choose only catastrophic plans.
  • Lower subsidies, which would be possible because the plans would be cheaper.
  • Other options include allowing state experimentation and the development of regional healthcare plans.

Even President Obama acknowledges that changes to the ACA are necessary. Some minor changes might get passed in the next two years, but Republicans have until early 2017 to coalesce around a proposal for major reform of our healthcare system. They should make their decisions by reconciling what is in the long-term interest of our nation (in terms of affordability and equity), what is possible to pass after the 2016 elections, and what will be acceptable to the citizenry—which may be three different things.

What parts of the Affordable Care Act do you think most need revising?

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The Obamacare Squeeze


Supreme Court building, from Wikipedia

Supreme Court building, from Wikipedia

We will know much more about the future of Obamacare (the Affordable Care Act, or ACA) after the Supreme Court rules later this month in King v. Burwell.  That case will decide the future of tax-credit subsidies to individuals purchasing health insurance on exchanges run by the federal government, rather than by the states. These subsidies are an important element of the ACA design that encourages lower- and middle-income individuals to buy coverage.

But King v. Burwell is not the only issue under Obamacare that confronts Americans, their employers, state governments, and the federal government. There are other structural issues in the ACA design that will require rethinking, no matter what the Supreme Court decides.

The U.S. system of financing healthcare has been a morass at least since employers became involved in the 1940s, when employers began offering health insurance to their workers in lieu of raising wages under World War II price and wage controls. Healthcare financing got more even complex when healthcare costs started rising much faster than inflation, requiring employers to start managing costs more closely.

Healthcare Reform: Know Thine EnemyAnd now, with Obamacare, the financing of healthcare is being complicated even further. Under the ACA design, consumers and providers are getting squeezed on all fronts, and the squeezes will get tighter in the years ahead, no matter what the Supreme Court decides in King v. Burwell.

Here are the reasons for the squeeze on employer plans:

1. MANDATED BENEFITS

Healthcare plans must include an ever-broadening list of products and services. This started prior to the ACA with a variety of state mandates. But the ACA federalized the mishmash of state requirements. Now, to qualify as an acceptable plan under the ACA, healthcare insurance must provide “essential health benefits” in ten categories. There are only narrow exceptions permitting people to choose catastrophic coverage, and they still cannot any categories of benefits they don’t think they will need. This is like requiring every car owner to carry not only liability coverage, but also collision coverage to the full replacement value of the vehicle and roadside assistance as well.

     2.  “AFFORDABLE” COST

Healthcare plans cannot cost too much. Employer plans under the ACA must have an option that offers “minimum essential coverage.” This coverage must include all the “essential health benefits” and must cover at least 60% of the cost of those benefits. Moreover, such a plan must not charge more than 9.5% of household income for the employee’s share of individual coverage. If the employer does not provide such an option under its healthcare plans, the employer will have to pay a substantial penalty per employee.

     3.  BUT NOT TOO GENEROUS

Employer healthcare plans cannot provide too much in the way of subsidies. In 2018, the so-called “Cadillac tax” will kick in for employers who provide more than $10,200 in individual coverage or $27,500 in family coverage to their employees (amounts adjusted for inflation). The Wall Street Journal reports that most employers think they will exceed these thresholds with their plans as currently designed by 2018 or soon after.

Because of these factors, employer-provided healthcare benefits plans are in a vise. The floor is the benefits that must be covered . . . and Obamacare raised that floor. Both sides of the cost equation are pushing in. Obamacare sets the maximum that employees can pay (and the 9.5% maximum will rise only as fast as wages rise) and also sets the maximum that employers can pay (which will go up at the rate of inflation).

Over time, more and more employers will be forced into a Hobson’s choice: (1) pay the increasing costs of healthcare to keep their plans “affordable”, which leads to the Cadillac surtax, or (2) drop employee healthcare benefits, which leads to employers paying the penalties for not offering “minimum essential coverage”.

Regardless what happens in the Burwell case, Obamacare is not sustainable from employers’ perspective.

We are long past the days of complaining about President Obama’s inaccurate statement “if you like your healthcare plan you can keep it.” We now must wonder if we can keep employer-provided healthcare at all. And if we can’t keep employer-provided healthcare, how will Americans pay the unaffordable costs of “essential health benefits” without subsidies?

Should we reconsider linking healthcare coverage with employment?

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Obamacare at the Supreme Court Again: Is a State a State?


Supreme Court building, from Wikipedia

Supreme Court building, from Wikipedia

Last week the Supreme Court heard oral arguments in King v. Burwell, on the issue of whether the Affordable Care Act authorizes the IRS to grant subsidies to people buying health insurance through the federal exchange, Healthcare.gov, or only to people buying health insurance through state-run exchanges. The debate focuses on Section 1401 of the Act, and in particular on the phrase that provides that subsidies are available to people who buy their insurance “through an Exchange established by the State.”

Does the quoted phrase mean only exchanges established by the state, or does it also mean exchanges established by the federal government? The plaintiffs argue for a plain meaning of the words—a state is a state. The government argues that Congress couldn’t possibly have intended to only help people who used state-run exchanges, particularly because it turned out that most states did not create their own health insurance exchanges. The government says the phrase is ambiguous and the IRS interpretation is reasonable.

However, one of the Senate bills leading up to passage of the ACA did condition exchange subsidies on state cooperation, and some House Democrats complained. Still, the plain meaning of the final language of the ACA appears to limit the subsidies to state-run exchanges.

Moreover, an early draft of the IRS regulations interpreting the subsidy provision originally restricted the subsidies to state-run exchanges. Only when the issue began to be publicized in 2011 did the IRS change their interpretation of this section.

It is likely that no Democrat would have passed a bill that kept citizens of more than half the states from getting subsidies on the federal exchange. It is likely that they never anticipated that more than half the states would decline to establish an exchange.

This is another example of why complex statutes almost always need technical corrections. The problem is that the Democrats don’t have the votes to pass the corrections they need.

Because of the way that the ACA was passed—with only Democrat votes in support, and all Republicans in Congress opposed—the law has no bipartisan underpinning to foster compromise. The Democrats are now reaping the effect of their actions in cramming the legislation down an unready nation’s throat.

So what will the Supreme Court decide in King v. Burwell?

Based on the oral arguments, it seems probable that four justices—Justices Breyer, Ginsburg, Kagan and Sotomayor—will vote to uphold the IRS interpretation and provide subsidies to people who used the federal exchange. It seems likely that three justices—Justices Alito, Scalia and Thomas—will vote to overturn the IRS interpretation.

As is often the case, Justice Kennedy is harder to read, but asked questions indicating he was uncomfortable with the practical result of overturning the IRS regulations. On the other hand, Justice Kennedy voted to overturn the individual mandate the last time Obamacare reached the Supreme Court, in National Federation of Independent Business v. Sebelius, decided in 2012.

Chief Justice Roberts said very little during the King v. Burwell oral argument on March 4.

My prediction is that we will either have a 6-3 vote to uphold the IRS interpretation, or we will have a 5-4 decision against the government. I think the Chief Justice will want to be in the majority on this case, so he can at least assign the opinion, and quite likely keep it for himself. That way, he can shape the future of the Affordable Care Act, as he did in National Federation of Independent Business v. Sebelius.

In that case, Chief Justice Roberts turned the individual mandate that the Democrat proponents of the ACA had very carefully not called a tax during their negotiations over the law into a tax, in order to uphold the mandate under the Constitution.

If the IRS regulation is upheld because the statutory language is ambiguous—which is the best the government can hope for—then the next Administration could rewrite the regulation.

It seems Nancy Pelosi was wrong. It takes more than passing the law to know what’s in it. It takes several years of legal battles that go up to the Supreme Court, so the nine justices can decide what the thousand-page law means. It would be better if both Republicans and Democrats compromised, and we developed a workable healthcare system. The system we had before Obamacare was not working, and the ACA system is not working.

Sausage and statutes. As Otto von Bismarck said, it is better not to watch them be made. Some of us, however, revel in the goriness.

What’s your prediction on the decision in King v. Burwell?

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Increasing Problems for the Affordable Care Act—In the Courts and In the Boardrooms


In recent weeks, the Affordable Care Act (popularly known as Obamacare) has suffered several setbacks and conflicting interpretations in the courts. These decisions and the impact of the law on employers show the increasingly urgent need for changes in the ACA. Unfortunately, our political mood is unlikely to result in the kinds of changes businesses need for clarity.

Recent Legal Decisions:

The Supreme Court ruled in Burwell v. Hobby Lobby Stores, Inc., June 30, 2014, that privately held corporations need not comply with the HHS mandate to cover birth control methods and services that violate the owners’ religious beliefs in their employee healthcare plans.

A few days later, the Supreme Court ruled in Wheaton College v. Burwell, July 3, 2014, that Wheaton College need not comply with the HHS work-around for employers who disagree with the birth control mandate. Wheaton College was allowed to avoid sending the notification HHS required until after its case is decided sometime next spring.

HHS sealAnd then on July 22, two Circuit Courts ruled opposite ways on the question of whether Obamacare subsidies are available to individuals who purchased their insurance through the federal Healthcare.gov exchange instead of through state exchanges. In Halbig v. Burwell, a panel of the D.C. Circuit Court ruled that the Obamacare subsidies were not available through the federal exchange, while in King v. Burwell the Fourth Circuit ruled that the subsidies were available.

The D.C. Circuit panel held that the plain language of the ACA states that subsidies are available only on marketplaces “established by the state.”  This ruling eliminates—or at least places on hold—subsidies to around 4.5 million people, which may make health insurance unaffordable for many, and yet will subject them to penalties if they drop their coverage.

In contrast, the Fourth Circuit held that the Internal Revenue Service interpretation permitting federal subsidies for purchases through Healthcare.gov was “a permissible exercise of the agency’s discretion.”

These cases set up a clear split in the lower courts that the Supreme Court will likely have to decide.

Impact of the ACA on Employers:

Increasing numbers of employers are finding themselves squeezed between the mandated coverages (more generous and more detailed than most employers offered before passage of the ACA) and the required level of premiums (where at least one plan that an employer offers must have premiums for individual coverage that are no more than 9.5% of any employee’s wages).

When the Cadillac coverage provisions go into effect after 2017, employers will face yet another constraint. If they pay too much for their employees’ coverage, they will face huge surtaxes. Beginning in 2018, a 40 percent excise tax will be imposed on high-value healthcare plans

Thus, the sweet spot of permissible healthcare plans under the ACA is being compressed in three directions—by the coverages required, by the amounts that employees can be charged, and by the subsidies that employers can provide.

And now, depending on how the Supreme Court rules on the subsidy issue, the federal government may not be able to subsidize healthcare coverage either.

Moreover, if the federal subsidy is ruled to be unlawful, then the employer penalties for employees who get the federal subsidies will fall apart as well.

At that point, the ACA scheme is likely to collapse.

I have talked with benefit plan managers in recent weeks about the increasing problems and uncertainties they face in complying with the ACA. Some are considering eliminating their employee health insurance altogether, and taking the chance that the employer penalties will survive.

Others are considering moving to fully insured plans to eliminate the complexities of complying with the uncertain ACA requirements. These employers believe they have so little flexibility in designing plans to suit their employee populations that they see no benefit to maintaining any in-house expertise in managing healthcare. Instead of continuing the tailored benefit plans they have sponsored for decades, they will turn their employees over to private exchanges, and let the employees find their own plans.

None of these benefit managers believes that employee healthcare coverage will last many more years. As crafted under the ACA and as interpreted by current HHS regulations, employee healthcare coverage has outlived its usefulness.

The Need for Change:

Most complicated statutes need “technical corrections” after the language that Congress passed is examined more carefully by regulatory agencies and by those impacted by the new law. It was to be expected that the ACA would need modification.

I have written before that the ACA needs to be amended. Not repealed, as Republicans would have it, but amended substantially. Unfortunately, changing the statutory language will require compromise between sharply divided political parties.

Employers, Be Strategic In Implementing Health Care ReformBecause of the way that the ACA was passed—with only Democrat votes in support, and all Republicans in Congress opposed—the law has no bipartisan underpinning to foster compromise. The Democrats are now reaping the effect of their actions in cramming the legislation down an unready nation’s throat.

In the meantime, we must muddle along with imperfect legislation.

Unfortunately, President Obama’s unilateral actions in delaying and re-interpreting the ACA the way he wants is not the way to fix the law.

So the healthcare industry holds its breath, hoping that the myriad issues associated with the poorly written ACA get fixed before the industry collapses due to the uncertainty.

And all of us who need healthcare hold our breaths as well.

What do you foresee happening with the ACA?

 

 

 

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Obamacare and the CBO Report: The Truth Is in the Middle


800px-Capitol_Building_Full_ViewLast week’s kerfuffle over the Congressional Budget Office (CBO) report on Obamacare, like most kerfuffles, had some truth on both sides of the debate. The CBO report says that the equivalent of 2 million full-time jobs will disappear by 2017, and 2.5 million by 2024, in part because people choose not to work at all or to work fewer hours. Is this a liberation of the oppressed American workforce or a death-knell to the American work ethic? Obviously, it is neither completely.

The Affordable Care Act grants subsidies to lower and middle income families to buy health insurance on the exchanges. Subsidies are just a way to give people money, albeit money with restrictions. In this case, people get the money (the subsidy) only if they buy insurance.

If you give people money, they have more choices. People will always choose to use the money in ways that they think will benefit themselves. Some of their choices also benefit society, and other choices do not.

Source: National Cancer Institute

Source: National Cancer Institute

With respect to healthcare, most people have had their health insurance subsidized by someone in the past.  Many received subsidized health insurance from their employers. Many others were covered by Medicare or Medicaid government subsidies. Only those on the individual market who could not tap into a high-risk pool paid for the insurance entirely on their own.

The Affordable Care Act now grants many people another government-subsidized option—health insurance purchased through the federal and state exchanges. So what choices are likely to make as a result of this new option? And will those choices benefit society or only the individuals involved?

  • People will quit jobs they don’t like because they no longer need employer-subsidized healthcare. This is the “benefit” described in the CBO report that the Democrats are touting.

It is true that many employees have stayed employed at a particular workplace only because they need health insurance. Prior to the ACA, employees younger than 65 may only have had the choice of employer-subsidized health insurance or unsubsidized private insurance that they thought cost too much. A second earner in a household might have been working primarily to provide health insurance, rather than because the family needed the salary. Those with pre-existing conditions didn’t feel they could get insurance if they changed jobs or quit work.

So “job lock” is real. Anyone who has worked in Human Resources or managed a workforce knows that many employees would rather be doing something other than working, and often their motivation for staying is related to insecurities around healthcare.

To the extent that the ACA has de-linked health insurance from the workplace, Republicans should extol this benefit. The problem is that the ACA doesn’t de-link insurance and employment. The ACA in fact imposes substantial penalties on employers if they do not continue to provide health insurance to employees. The ACA provides subsidies to employees but increasing costs on employers.

  • People will work less to keep their ACA subsidies. This is the impact of the ACA described in the CBO report that Democrats ignore and Republicans squawk about.

Many government programs give money to people but reduce the amount they receive as their income increases. Most of those programs therefore cause people to question whether they are better off maximizing their government payments or maximizing their income. Some will choose to work less to receive a larger payment from the government. Clearly, ACA subsidies will cause some of this behavior.

Moreover, it appears from the CBO report that lower income workers are more likely to decrease their work hours in response to the ACA. That is because they receive the greater subsidies, and the trade-off between their salaries and their ACA subsidies is more likely to favor the subsidy.

These choices to take the subsidy rather than work more for pay may benefit the individual, because non-working hours are valuable for family, hobbies, and other personal priorities. But the choices do not benefit society, unless someone else performs the same work for less pay or more work for the same pay. If productivity from new workers does not increase sufficiently to cover the cost of the subsidy, then society is worse off.

Even most conservatives believe that some redistribution of income to the poor through government programs is desirable; the question is how much. While I don’t think the ACA itself is the tipping point, I do believe that it will incent some people who could work more to instead work less, and in many cases, that will not benefit society.

So the CBO report contains ammunition for both sides of the Obamacare debate. While I believe the conservative arguments in response to the CBO report are over the top, I also believe that the liberal arguments are ignoring the very real likelihood that the ACA subsidies will decrease productivity.

The bottom line is that after the CBO report, the political argument around the ACA remains what it always has been—a debate on the role of government. Is it better for people to work less and receive more government support at taxpayer expense, or is it better to spend less on government programs and make people cover more of their expenses themselves? Should we redistribute income or not?

For employers, however, Obamacare is still bad news. Employers remain on the hook to provide subsidized health insurance to their workers or face substantial penalties. Moreover, the disparate taxation of employer-provided healthcare and privately purchased healthcare continues. In these ways, the labor market continues to be skewed, and therefore I still believe that the ACA has not moved healthcare in this country in the right direction.

For one of the more reasoned discussions of the CBO report, see Obamacare: ‘Job-killer’ or freedom from ‘job trap’?, by Linda Feldmann, Christian Science Monitor, February 6, 2014.

For a good articulation of the philosophical arguments on the role of government, see Leaving Work Behind, by Ross Douthat, New York Times, February 8, 2014.

What are you hearing from your employees about the Affordable Care Act these days?

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Obamacare: Get People Enrolled, then Amend It—Fast!


doctor holding an injectionBased on my earlier posts about Obamacare (see here, here, and here), readers might think I hope the new law fails. That is not the case. I do not agree with the legislation’s design. I originally hoped Congress would repeal it or the Supreme Court would invalidate it. I still hope it will be changed significantly (as outlined below).

But we are well past the time when anyone—even the staunchest Tea Party member—should hope Obamacare (formally known as the Affordable Care Act) fails completely. The quality of every American’s future healthcare is at stake. We are beyond the point when we could return to the healthcare system of the past.

In the short term, it is clear that we cannot return to the past for the reasons we have heard since President Obama asked insurance companies to consider reinstating their old plans, so he could keep his promise that if we liked our plans, we could keep them. (A promise that was never true, as the rapid decline in the number of grandfathered employer plans demonstrated in 2012 and 2013.)

Through the course of 2013, insurance companies blew up their old policies, provider networks, coverage options, premium levels, and every other aspect of their healthcare delivery systems to comply with the mandates of the ACA. Even if state insurance commissioners permitted healthcare insurance companies to reinstitute their old plans, most insurers could not do so before January 1, 2014. Even if they could, they would likely see adverse selection, with younger, healthier people selecting the cheaper old plans, and older, sicker people selecting plans that meet the ACA standards.

If we don’t get people enrolled in the insurance plans we now have, many families will suffer when they incur medical costs starting in January. But, it is also time to step back and reassess Obamacare.

We first need to recognize that healthcare insurance will only survive with some form of subsidy. For the past several decades, our healthcare system—as bollixed up as it has been—survived because of employer subsidies. Employees paid nothing or very little for their healthcare coverage. Even in recent years, employees have paid only a fraction of the cost of their coverage; the rest was paid for by their employers.

Government subsidies have supported the healthcare system also, in the form of Medicare and Medicaid, but employer subsidies have been what kept the young and healthy workers in the healthcare system and allowed the sick and elderly to pay less than their healthcare cost. Employer and government subsidies also led to the lack of consumer knowledge about healthcare pricing and quality, and the consequent overuse and wastefulness in our healthcare system.

It was an accident of history that led to the development of employer subsidies. We had an opportunity to correct that accident before the passage of Obamacare, which we let slip by. The failure of the Obamacare rollout gives us another opportunity to correct the past.

So, where do we go from here?

1.  Get People Covered: The first order of business should be to get as many people as possible covered under some healthcare plan—whether it be an ACA-compliant plan or a resurrected individual plan or an employer-sponsored plan. Republicans and Democrats, state and federal agencies should all work toward that short-term goal in the next month . . . and continuing until the March deadline.

HHS seal2.  Amend Obamacare: Both Democrats and Republicans recognize the ACA is far from perfect. Any other legislation of this magnitude would have gone through one or more rounds of “technical corrections” after its passage. Unfortunately, the acrimony around the passage of the ACA insured no technical corrections bills could be passed. Only Democrats voted for the ACA, when the Senate bill that was never intended as final legislation was rammed through the House. We now need a bipartisan replacement for Obamacare.

3.  Keep Parts of the ACA: Some of the Obamacare provisions are popular and should be retained. One of those is the requirement that young adults be permitted to stay on their parents’ coverage. Easier transfer between healthcare plans, regardless of pre-existing conditions also needs to be a component of future legislation, but how to keep insurers whole is the crux of the problem.

4.  Revise Other Aspects of the ACA:  Even the Obama Administration has acknowledged that some aspects of the ACA are unworkable. Implementation of some provisions has been delayed. Regulations have changed other provisions away from the clear language of the statute. Other provisions are wildly unpopular.

Here are some broad suggestions for reform:

  • Put all forms of health insurance on an equal footing: Allow all taxpayers to deduct their healthcare premiums, up to a maximum amount, regardless of whether healthcare is obtained through employment or on an open market. In addition, employer subsidies of healthcare costs should be taxable as ordinary income. Some employers will continue to provide healthcare plans, and others will convert that benefit to wages. Those that do neither will lose employees.
  • Permit a wide variety of insurance plans: Individuals should be free to purchase only catastrophic plans, to choose high-deductible plans, or to buy a wide variety of coverage and exclusions. They should be allowed to buy plans that exclude preventative coverage or certain types of coverage (psychiatric, substance abuse, maternity and contraceptive, etc.). Then we need to be willing to hold people accountable for their choices, but permit movement between plans at some price.
  • Provide direct subsidies to the poor and seriously ill: We should provide subsidies directly to the poor and the seriously ill to permit them to purchase healthcare coverage on the open market, and to make the transfers between plans as their healthcare needs change beyond their ability to pay. There should be a robust pool to fund these subsidies, paid for by premiums of those who are covered and by both state and federal governments. States should be allowed to change their Medicaid programs to integrate coverage for the indigent into the private market.
  • Repeal the individual and employer mandates: It would be better to repeal the unpopular individual mandate, but if any mandate is retained, it should be limited to requiring that people maintain catastrophic coverage or be taxed on their share of the pool needed to fund public subsidies. (Yes, call it a tax—that is what the Supreme Court said it is.) In addition, the employer mandate would no longer be necessary if private insurance would be taxed on the same terms as employer coverage.

In short, the type of healthcare insurance to buy should become a decision that individuals make, not the government. Insurers should be free to design policies that consumers want, and to price them at levels that are profitable. We should abandon the notion that the federal government knows what one-size-fits-all insurance programs are “best” for Americans.

If we do not abandon the central-planning model in Obamacare, we will drift—and I think drift quickly—into a world where healthcare is rationed by the lack of providers and by the government decisions on what services will be covered at what level, where fewer and fewer Americans have access to the doctors they want, and where the quality of care suffers.

Will Republicans and Democrats be able to compromise to reform Obamacare during the 2014 mid-term election year? What do you think?

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