Fixing The ACA Mess: Calling A Spade A Spade

caduceus-obamacare-cartoonTrue or False: All of our elected leaders would honestly like to come out of the “Repeal/Replace The ACA” versus “Fix/Enhance the ACA” war with a bipartisan solution that provides the best possible care for Americans at the lowest possible cost that we can afford. They just have differing views on what is the best way to reach that goal. … Unfortunately, as much as we might like to think the answer is “True”, it is “False”.

So What Outcome Would They Honestly Like?

For each Legislator, regardless of party affiliation, the short answer is two-fold [listed here in descending order of importance]: 1) “a solution that maximizes my personal chances of being re-elected”; and 2) “a solution that maximizes my party’s chances of keeping or gaining control of the Senate, the House, and the Presidency”. Personally, I honestly believe President Trump wants the more altruistic outcome [“True” above], but he is quickly learning that, absent a complete “draining of the swamp” first, it will be politics [“False” above] that drives the process.

Getting rid of these political drivers [so that logical thinking could creep into the minds of our leaders] would require one of two things: 1) at least eight Democrats in the Senate who would get on board with a bill that is characterized as Repeal/Replace; or 2) at least three Republicans in the Senate who would get on board with a bill that is totally void of even a hint any Repeal/Replace terminology and characterized more like “making the ACA even more perfect than it already is”. If #1 happens, I will assume that these eight Democrats will have gotten insider information about an approaching meteor that will completely destroy our planet before they are up for re-election. There is a better chance that #2 could happen, but when push comes to shove, I seriously doubt that it will. So since politics will likely continue to drive the process, let’s see if there is a logical, straightforward approach that even a dyed-in-the-wool career politician may be able to grasp conceptually. My hope is that any who do will be able to pursue this approach, package it however necessary to make it politically palatable to their colleagues, and move us toward a workable and sustainable solution.

It’s Not Rocket Science!

Note. I have written extensively on the subject of repealing and replacing the ACA [numerous blog posts, much of the content of which has been captured in this special page at this site: Repealing And Replacing The ACA].

It is incomprehensible to me that all legislators, in both parties, seem to be failing to grasp the easiest way to simplify the whole Repeal/Replace The ACA process: break current enrollees down into the three categories that are driving the costs, and proceed to tackle those three areas separately [but still simultaneously]. The three areas? … 1) Medicaid/CHIP expansion [CHIP, the Children’s Health Insurance Program, provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid], 2) people who have obtained coverage under the ACA because they could not obtain coverage any other way, and 3) all other people who obtained coverage through the ACA exchanges.

Pinning down the total number of people who have health insurance obtained under the ACA, either because the expanded Medicaid/CHIP coverage made them eligible or because they purchased it through the Federal exchange or one of the State exchanges, is a task that requires more time than I was willing to consume to make my point in this post. So let’s just use the number all the “keep the ACA” folks keep yelling and say it’s 24 million people. Now let’s break that number down into the above three categories. …

Category 1 is the most accurately quantifiable of these categories. 17.1 million people have been added to Medicaid/CHIP rolls since passage of the ACA and phase-in of these features within it [Source:]. This could be overly optimistic, though [in terms of attribution to the ACA], because some sources estimate that as many as 2.1 million of these enrollees were eligible for these programs before passage of the ACA, but not enrolled [e.g., because they didn’t know they were eligible]. Since using the higher number could make it appear that I might be “fudging” to make my point, let’s just say there are 15 million people in this category [17.1 million minus 2.1 million].

Category 2 is almost impossible to quantify to any reasonable degree of accuracy because there is no way to trace why any particular enrollee obtained coverage through the Federal exchange or one of the State exchanges — i.e., because he/she found it more convenient, or because he/she had no other way to obtain coverage. The highest estimate I have found of the percentage of people obtaining insurance through the ACA exchanges because they could not get a policy any other way is 82% [I have referenced sources in previous posts on repealing/replacing the ACA]. To keep things simple, let’s just use that high-end estimate.  82% of 9 million [24 million minus the 15 million in category 1] puts 7.4 million in this category.

Category 3, of course, is dependent on how many enrollees are in Category 2. Under the logic described under category 2, there are 1.6 million people in this category [9 million minus 7.4 million].

Next, let’s recognize a fact that seems to be eluding all lawmakers: the people in category 1 are there not because of the bulk of the content of the ACA and all its complexities, but because of expanded eligibility for entitlement programs that were in operation decades before the ACA became law. Their coverage could have been provided through passage of a one-page law that simply expanded the eligibility thresholds for those programs and provided exactly the same Federal reimbursements to the States that are outlined in the ACA.

There’s another thing that none of our legislators seem to realize [or if they do, they are (surprisingly) not articulating their thoughts about it in media interviews]. Comparing how many people would be covered X years from now under the [new] AHCA with how many would be covered under the [current] ACA is a ridiculously meaningless statistic because the ACA is not sustainable in its current form [even Democrats reluctantly (and tactfully) agree with that].

So What’s The Deal?

So if all the Chicken Little “The sky is falling!” legislators could just dispense with that rhetoric, and if the RINO [Republican In Name Only] element of the Republican party could take this simplified [and I would argue, more accurate] view of the task at hand, it should be possible to actually come to a bipartisan solution built around two components: 1) deciding whether to continue funding expanded Medicaid/CHIP coverage [which will affect people in category 1]; and 2) developing a new healthcare financing system that deals with people in categories 2 and 3. To the extent passage of the resulting law causes people in any of the three categories to initially lose their coverage, just call a spade a spade [i.e., “We simply can’t afford the cost of that big an expansion of the decades-old Medicaid/CHIP programs” for people in category 1] and include a transition or bridge plan for people in categories 2 and 3 that avoids abrupt coverage loss and allows them to transition to the new system outlined by the AHCA.

The Chinese philosopher Lao Tzu said “If you do not change direction, you may end up where you are heading.” I hope our legislators realize the truth in this statement, as well as the truth in Lewis Carroll’s statement “If you don’t know where you’re going, any road will take you there”. Right now, our legislators are frantically trying to put together a politically palatable solution [which means they’re simply shifting with the wind]. It’s time to wake up and get this done!

img_7026  Charles M Jones

Charles M. Jones

Author: Charles M. Jones, PE, CPA

[retired — neither license active]

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