Repeal and Replace – An Irresponsible Solution to Fixing our Nation’s Health Care
By Richa Shukla, MD
Affordable Care Act (ACA), also known as Obamacare, has been a contentious, divisive law from the point of its inception in 2010. Its repeal was one of the major campaign promises upon which 45 won the 2016 presidential election. One major argument against the ACA has to do with the cost it imposes. It is estimated that there will be an average 25% increase in premiums by this year. Premiums are rising, in part, because many insurers underpriced plans when they started selling policies on the insurance marketplace in 2013; they did so in hopes that healthy, “low health care utilizers” would sign up. What ended up happening, however, was that not enough healthy, younger people signed up, and those who did required more health care than the insurers anticipated.
As a result, some insurance companies such as United Health Care and Aetna have pulled out of insurance marketplaces while other companies have substantially increased their premiums. These premiums have risen the most in states where there are three or less insurance companies on the exchange and therefore little competition in pricing. Despite this fact, the plans available on most insurance marketplaces are less costly (anywhere from 10-21% less) than what was previously available on individual marketplaces; moreover, these plans provided access to more medical care than the plans they replaced.
Another point of contention is the individual mandate – one of the provisions of the ACA that requires US citizens and legal residents to have qualifying health coverage or pay a tax penalty. In 2016, the penalty was the greater of $695 per person or 2.5% of household income. Republican lawmakers have argued that the mandate was unconstitutional all the way up to the Supreme Court in 2012; ultimately, this was ruled to be constitutional. The individual mandate is one of the more unpopular provisions of the ACA however it makes room for one of the most popular provisions – the inability to deny coverage on the basis of pre-existing medical conditions.
At present, Republican leaders claim to be charging forward with the promised repeal while also reassuring the country that some nebulous, but reportedly “better”, replacement is soon to follow. The ACA has extended insurance to over 20 million people who now are at risk of losing this vital coverage. At this key moment in our health care environment, it is important to closely examine the benefits the ACA offers to the millions of people in this country receiving coverage under the law.
As mentioned above, one of the most important stipulations of the ACA is the mandate that prohibits insurers from denying coverage to those with preexisting health conditions. It is undeniable how important this part of the law is, especially in light of the fact that an estimated 133 million Americans, nearly 1 in 2 adults, suffers from a chronic medical illness that would qualify as a pre-existing condition.
Because of the ACA, those with a preexisting condition cannot be denied coverage, cannot be denied access, and cannot be charged exorbitant rates because of their health. This affords these people the opportunity to take advantage of the health care they need that could potentially alter the course of their disease and reduce the overall morbidity and mortality related to their illness.
Other favorable parts of the law include the ability to keep dependents on a health care plan until age 26, thereby offering young people who are just entering the workforce or pursuing additional training, such as graduate school, the security of knowing their health care needs can be covered for a little longer by their parents. The ACA also prevents insurers from imposing lifetime and annual benefit caps on health care spending, this greatly helps those diagnosed with conditions, like cancer, requiring frequent and expensive care.
Narrowing the focus to our state’s “microcosm”, health care in Texas may be particularly dire straits as compared with the rest of the country. Texas has one of the highest rates of uninsured populations in the United States. In 2014, it was estimated that 5 million people, 1/5 of the Texas population, was uninsured. The ACA originally envisioned expansion of Medicaid in all states to extend health care coverage to all non-Medicare eligible individuals under age 65 (children, pregnant women, parents, and adults without dependent children) with incomes up to 133% of the federal poverty level.
However, the 2012 Supreme Court decision made this expansion optional and Texas stubbornly refused to expand Medicaid coverage. The uninsured rate in Kentucky and Arkansas, two Southern states that did pursue Medicaid expansion, dropped from 41% to 16% from 2014 to 2015. In Texas, however, this drop was much more modest, from 39% to 27% - some low-income families were able to purchase insurance on the marketplace through tax credits given through the ACA. Texas’s decision not to expand Medicaid also affected the ability of low-income adults to pay for and obtain care. Why does this matter? When more people have insurance and can pay for their health care, this lessens the burden on taxpayers who fund charitable, tax-funded hospitals like the Harris County Hospital District where I currently practice.
As a physician practicing in a low-resource, county hospital setting I have witnessed, first-hand, the negative consequences that come from not being able to pay for adequate health care. I have seen a young man with ulcerative colitis, a condition that causes significant inflammation in the colon, be forced to surgery to remove his colon simply because he could not afford the recommended medical therapy. I have seen a woman with refractory Crohn’s disease, another condition causing inflammation in the small and large intestine, be able to take advantage of an effective and innovative treatment because she signed up for health insurance coverage through the ACA. I can tell many more stories of success and failure related not to the course of disease but simply to the ability to pay for coverage. The ability to take care of oneself and to address one’s medical issues should not be dependent on financial security. Therefore, it is imperative that our government maintain a route to health care coverage for all.
Rather than a repeal of the ACA and a replacement that may or may not come (depending on the priorities of our majority Republican lawmakers) and, frankly, may or may not be better than what we currently have, our lawmakers should consider improving the plan we currently have. By no means is it a perfect law, but it does provide a framework upon which our lawmakers can work together to build a stronger health care system. Some suggestions for improvement would be to again revisit the issue of Medicaid expansion in those states that do not have this. This would afford insurance coverage to lower income families who are often higher utilizers of expensive health care, like emergency room services.
Working to expand tax credits to lower income families would be another way to improve the rates of those buying insurance on the marketplace. Though a controversial issue, it seems that the individual mandate must persist in order to ensure healthier people are signing up for marketplace plans and thus balancing the overall costs; in order to do this, the exemptions to the individual mandate may need to be narrowed. In addition to Medicare and Medicaid, the government could consider creating a public health insurance plan that could serve as competition to private insurers on the marketplace and help to keep overall costs down.
In short, a simple repeal of the ACA is a myopic solution to our nation’s health care problems. I emphasize again that our Congressional leaders should instead work to fix an effective but imperfect system that we already have in place in the form of the ACA.
Richa Shukla, MD is a practicing gastroenterologist in Houston, TX. She has several years of experience working in low-resource medical settings and is passionate about advocating for patients in underserved areas. She is involved with health care advocacy in the Houston area.