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.