A couple of days ago P.A. asked a good question in comments:
but can you (David) discern any meta for the ACA over the near term (3-ish years)? The sabotage doesn’t seem to be working currently, but is the foundation sturdy, or in future danger given current design? (In effect not asking you to crystal ball future rethug sapper efforts)
This is highly conditional on the midterms.
If, on January 4, 2019, there are 53 Republican Senators and 228 Republican House members, then we’ll most likely get something that looks a lot like Graham-Cassidy with block grants and major Medicaid cuts. I am clueless as to what a 52 GOP Senate, 218 GOP House looks like in 2019 on health policy.
If the next Congress has a Democratic House, then we muddle through until at least 2022, if not 2023 as the best case scenario of a Democratic trifecta would need eighteen months or more to implement any new major legislation. If there is a split government, then we get more muddling through.
Let’s work with the assumption that there is a Democratic House in 2019. At this point, the ACA will be a patchwork quilt. It will work well in some states. It will be a mess in other states for anyone who is not getting a significant subsidy. I don’t think we should be too worried about bare counties. I think that enough insurers and regulators realize that a single insurer region is a gold mine of federal subsidy money.
States will continue to apply for and have 1332 reinsurance waivers approved. I think blue states will be tying their reinsurance waivers to the funding generated by state level individual mandates. States that don’t want to go down the individual mandate route will use small amounts of state funding to seed their waivers.
I think SilverLoading may be gone in 2020. This will make almost everyone no better off and many people worse off. CSRs will never be funded. CSR incremental costs will be borne by broad-loading.
I expect more states to start moving to their own exchanges or regional exchanges. HC.Gov is currently not a good partner as they charge a percentage of premium instead of a flat fee and as premiums have gone up, outreach has gone down. Enough state based marketplaces have stable software platforms that there are effectively plug and play exchange deals available. State based exchanges also enable far more complex waivers than simple reinsurance.
I think structurally the ACA can and will get to an equilibrium where its subsidy structure protects the individual market at least as a very well funded high cost risk pool for the 100-400% FPL population. All of the outs (Farm Bureau, Short Term Plans, no individual mandate) will raise premiums. Folks who are healthy and risk tolerant enough to take those outs will see lower costs. The people who are worse off and will continue to be worse off are the folks who can not pass underwriting and who make too much for subsidies.
But conditional on a Democratic House, I think muddling through is a plausible pathway.
Zinsky
David, it isn’t difficult to predict the ACA’s future – it’s DEAD! It was killed by the treachery of the Republican Party and a repulsive, ignorant sex offender named Donald Trump. The American people need to be reminded of this everyday. The Democrats need a message that says, “if you can’t afford health insurance or you don’t like your current coverage or if you can’t get health insurance at all, blame the GOP!” Every grievance surrounding health care needs to be stapled to the back of the Republican Party!
David Anderson
@Zinsky:
Politically that might be so.
Plumbing wise it is not the case on Medicaid expansion and <400% FPL individual market.
rikyrah
We must defeat them. They are evil people who want to take away healthcare for millions.??
Mary G
One of the reasons that the Republican Party fought the ACA and earlier efforts so hard was that they knew how much people would like it and want to keep the relative security/peace of mind that having even imperfect insurance brings. Obama and Pelosi and Reid got the foot wedged in the door and it’s not closing again. Look at how the polling has changed. It might not be the ACA, and it may take a decade, but we’re going to have something.
StringOnAStick
@Mary G: That was what I said to our two Canadian friends right after the ACA passed, that no matter what, having gotten the right to coverage passed that there would be no going back once it was established. It’s looking wobbly now for some of us (the non subsidized, better off cohort). The husband was shocked at how extreme the opposition was and how hard the US RW fought the passage of the ACA; I pointed out that it had been pretty hard fought in Canada too, but that was before he was born so he missed all the excitement. The first time the 4 of us met we had been asked over dinner to explain the US healthcare system (this was pre-Obama). I explained it, he looked shocked and said “that’s insane”.
As an aside, I noted that I knew something was up because once it was clear the ACA would pass, the opposition just plain stopped. I knew then that they were going to go for a nibbled to death response, and here we are. My husband and I saw the passage of the ACA as an eventual ticket to job freedom for us, but once we knew the results of the 2016 election, we knew we couldn’t take the risk of putting ourselves in the position of buying our own insurance.