What does last night mean for PPACA?
These are initial, pre-coffee thoughts and not all of the data is in. I’m also venturing away from technical comments and towards general political punditry which is not my strength, so please apply an appropriate discount to everything.
- Medicaid expansion is dead for at least the next two years. Utah and Wyoming will probably get waivers and that will be it. (90% confidence)
Not expanding Medicaid inflicted absolutely no cost on the veto players in any state that I can see. Larger Teabagging majorities are opposed to Medicaid expansion for Those People. The invisible portion of the Republican primary process is coming to an end sometime in the next hour or two, so no one who thinks they have a shot in 2016 can thread a needle for expansion.
- Arkansas may stop the private option expansion (60% confidence)
From my understanding, Arkansas needs 75% reauthorization and the governor’s signature every year for the private option. I don’t think either condition is in place for next year. This will destroy the financial stability of hundreds of thousands of people AND destroy the financial base of the Arkansas rural hospital system as those hospitals were replacing charity care and uncompensated care DSH payments with Exchange payments.
- At least 1 week of government shutdown will happen by next October (85% confidence)
- Employer mandate will go down (80% confidence) as well as medical device tax (97% confidence)
From a policy point of view, the Employer mandate is probably the least important pound of flesh for Republicans to claim. It does not do much for coverage, and it produces bad business level incentives as well as locking people into really crappy insurance that their job provides when they would be better off on the Exchange. This is a probably a good piece of policy. The Medical device tax has bipartisan opposition because medical device makers sit in too many districts and are raising a big stink. The only question is whether the revenue losses are offset. I would hope that as part of the negoatitations, the rest of PPACA is Halbig proofed. If it is, then Don Taylor would be right in that there is a window to talk health policy on both sides of the aisle. I don’t think that will be the case.
- PPACA will work in states where the states want it to work. It will be a clusterfuck in Republican base states.
- At least one Republican base state will start preparing Wyden Waivers for 1/1/17 which makes everything on Exchange an HSA style system with no EHBs. (60% confidence)
- Risk adjustments are at risk as they need appropriations
PPACA has three risk transfer mechanisms. Reinsurance and Risk Corridors are temporary stabilizers, and risk adjustment is a permanent program. The goal is to help insurers figure out what a stable market risk pool looks like by transferring money from low risk/healthier than average plans to high risk/high disease burden plans. The problem is that the way PPACA is written, money can come into the Federal government, and it can go out for 2014 payments, but it is questionable if it can go out in 2015 and 2016 without an appropriation.
- My hangover will subside by late afternoon (98% confidence, 100% hope)