What’s Next for the Affordable Care Act? (Part 2)

More answers from the KFF Marketplace webinar and a plea that five years of progress not be undone.

In its Feb. 10 webinar, the Kaiser Family Foundation (KFF) posed the question “What’s Next for the Affordable Care Act?” — and attempted to answer it with three more. Based on the impact of premium subsidies and their possible expiration:

Is the Marketplace broken or largely successful?

If the Marketplace is broken, how will future reforms succeed where past attempts have failed?

Are continued subsidies part of the problem or part of the solution?

The KFF event and its panel explored these questions from divergent viewpoints

1. Is the Marketplace broken or largely successful?

When asked how to prevent uninsured without premium subsidies, Brian Blase — President-Paragon Health Institute — made a blanket declaration,

“The Biden administration policies really juiced enrollment along with the expanded subsidies . . . They also created a Special Enrollment Period (SEP) for anyone claiming income between 100-150% of FPL to sign up at any point in time during the year.”

Blase added: “Now, if you combine that with the fact th

• greatly reduced funding for navigators who help people enroll

at they're also not checking income, I don’t think this is a well-run approach to a government program.”

Refuting these claims was Sarah Lueck, VP Health Policy-Center on Budget and Policy Priorities, who added that a “series of policy changes” made the Marketplace “a lot harder to access under Trump.” These included:

• shorter open enrollment periods
• more restrictions placed around SEPS

“I don't want to see that happen again,” Lueck added. “There were a lot of things changed for the better . . . just opening the door and giving people more opportunities and time to enroll was extremely important.”

The debated hinged on how the panelists viewed the Marketplace. Blaser cited the importance of stabilizing a deteriorating market during Trump’s first administration, while Lueck replied:

“We’re not talking about Marketplace stabilization anymore. We have to be careful and recognize where we are versus the environment of 2017. The Marketplace is working pretty well. There is record enrollment, and we don’t see huge drop-offs of enrollment during the year that we used to.”

2. If the Marketplace is broken, how will future reforms succeed where past attempts have failed?

Blase indicated he would want to “eliminate enhanced premiums subsidies entirely and focus on regulatory reforms.”

“Americans should have the right to spend their own money financing healthcare as they think best meets their needs.”

Here, Blasé includes short-term limited-duration insurance (STLDI) plans and his belief that they offer greater value via provider choice, benefits and affordability.

[STLDI has pros and cons, particularly as a replacement for comprehensive coverage and its adverse effects on the Marketplace. The first Trump Administration expanded STLDI options, lauded in Trump’s 2020 budget. The Biden Administration narrowed them again, For a refresher, revisit our two-part series.]

Blase also defines value as having skin in the game.

“Full subsidization discourages insurers from designing plans that enrollees actually value enough to pay a small fraction of the premium. This modicum of value helps protect against fraud.”

Lueck again rebutted: “Fraud is always raised as reason to tighten programs and cut spending by federal government. The Trump Administration is already looking at healthcare and other programs as a way to fund other initiatives.”

After the September debate between candidate Trump and then-Vice President Kamala Harris, Larry Levitt — EVP of KFF and moderator of its panel — noted the attempts of the first Trump Administration’s to look at healthcare.

“He did, in fact, propose the concept of an ACA replacement plan in his 2020 budget, though it has never gotten much attention . . . [It] would have repealed the ACA’s premium subsidies and Medicaid expansion, replacing them with a block grant to states. It also would have capped federal Medicaid spending. All told, Trump’s plan would have reduced federal spending on the ACA and Medicaid by over $1 trillion over a decade.”

3. Are continued subsidies part of the problem or part of the solution?

Here, Blase answers: “Proof that the ACA is broken is that affordability requires substantial subsidies that health plans then profit from. Insurers make more from government than the private market.”

“I think that’s a problem,” he continues. “Too much subsidization.”

Blase only supports continued subsidies at 400% FPL “until there are some broader ACA alternatives — especially for middle- and upper-income people.”

Neither Lueck nor the third panelist — Cynthia Cox, VP-KFF — cited specific alternatives. Confident that the Marketplace is working well, Lueck stressed that the tremendous progress of the past five years should not be undone.

“I think there's such a strong case to be made, even just thinking about the last election, that people want more financial security. They want lower costs out of their pocket.”

“We're in a place where we've made a lot of progress, and we certainly have a lot of work to do. But I think making more people uninsured, raising people's costs, reducing program eligibility, and making people go through more red tape to get coverage is going to be the wrong direction.”