Five Affordable Care Act questions for the GOP

SO, REPUBLICANS ARE planning a major blitz to repeal and delay/replace/collapse the Affordable Care Act/ACA/ObamaCare. I’ve got five questions to ask leaders of the Grand Old Party.

First, if your guarantees are honest that your replacement law will be better than the ACA, why not share real numbers?

President-elect Donald Trump, Speaker Paul Ryan, and Majority Leader Mitch McConnell have each promised that their ACA replacement will cover as many Americans as the ACA with higher quality and lower costs. Bully for that!

Here’s the problem. None of the plans you’ve produced, including the 2016 Reconciliation bill, Trump’s platform, Ryan’s Better Way, Health & Human Services Secretary designee Tom Price’s Empowering Patients First plan, or others from Republicans and conservatives, comes close. Except for this year’s reconciliation bill, none has been submitted to the Congressional Budget Office for a score. Reputable analysts peg the drop in insured lives between 20-30 million currently insured.

Your message is “trust us.” Would businessman Trump take such a deal?

Second, when you promise to continue “guaranteed issue” of health insurance with no-pre-existing conditions or medical underwriting, why do you always fail to mention the fine print?

Trump, Ryan, and other Republicans’ statements are clear – any reform will maintain “guaranteed issue.” Yet your written plans tell another story – guaranteed issue will be kept only for persons who maintain “continuous coverage” (undefined). This means if you lose your insurance and have a coverage gap beyond the allowed time, you will be newly subject to medical underwriting and pre-existing condition exclusions for an unspecified period (forever?).

How many people might fall into this new medical underwriting Circle of Hell (CoH)? Start with 28-29 million currently uninsured, add the estimated 20-30 million increase because of Republican plans to eliminate income-based premium subsidies. We start at 48-58 million Americans, and the numbers will only grow as more fall into the medical underwriting CoH.

This is detailed in numerous replacement plans, including Ryan’s. Yet you never mention this life-important detail when talking with media who buy your line that you will continue the ACA’s elimination of pre-existing conditions for everyone. Untrue.

Third, what will you do about enormous losses for those dealing with substance abuse and mental health needs under your plans?

Most Americans don’t realize that the ACA is the biggest law ever in covering Americans for substance abuse and mental health services (aka: behavioral health). It’s true. ACA guaranteed issue means no one can be denied insurance because they had or have substance abuse/mental health problems. Bans on lifetime and annual benefit limits allows countless persons with expensive substance abuse or mental health disorders to keep covered.  Requiring insurers to cover 10 “essential health benefits” insures that nearly all Americans have behavioral health coverage (#5) PLUS prescription drugs (#6) to treat their disorders.

All Republican plans – Trump, Ryan, Price etc. – propose eliminating “essential health benefits.” They propose eroding guaranteed issue (see above) and canceling elimination of annual benefit limits. So, the ACA’s enormous advances for  mental health and substance abuse would become major losses under Republicans’ plans. I’m not sure you get this at all.  I am certain most Americans have zero idea of this and they will strongly object when they find out.

Fourth, why are you so mean to the nation’s hospitals? 

In crafting the ACA, America’s hospitals committed a mortal sin in Republicans’ eyes by making a deal with President Barack Obama and the US Senate. In exchange for Democrats’ commitment to get as close to universal coverage as politically possible, hospitals agreed to $155 billion in federal payment reductions between 2010-19 (now about $350 billion between 2016-2025). They did this to stop being the default caretakers of America’s uninsured.

Now Republicans plan to repeal the ACA’s new taxes on wealthy Americans, on drug, medical device, and health insurance companies, even on indoor tanning salons! And, they plan to leave in place the $350 billion in payment cuts to hospitals even as their policies will send as many as 30 million recently insured Americans back into the ranks of the uninsured and back to America’s emergency departments.

The American Hospital Association and the Federation of American Hospitals, who brokered the 2009 deal, wrote a letter on December 7 to Republicans: “…any repeal legislation … must include repeal of the reductions in payments for hospital services embedded in the ACA.” Sounds reasonable to me, but maybe not to others because if Congress sends the money back, it will raise Medicare’s costs for the next decade and beyond, resulting in premium increases for Medicare enrollees across the nation, and shortening the lifespan of the Medicare Hospital Trust Fund (now solvent through 2028) by years. Sad!  (Read this excellent Kaiser Health Policy Brief for more details on the impact of ACA repeal on Medicare.)

Fifth, why don’t you just fix the ACA exchanges instead of killing them?

A parable: Last summer, Alaska realized that premiums in its health exchange and individual health insurance market would be rising in 2017 by over 40 percent. In response, the Republican legislature established a state reinsurance pool to protect insurers against high losses; after passing the law, insurance companies dropped their premium increases to about 7 percent.

Some health insurance exchanges (i.e., California, New York, Massachusetts) are working well, and some are having high rate increase problems. These problems are fixable with sufficient political will to address them.  The problem is that Republican lawmakers don’t want fixes – they want repeal. In 2014, 2015, and 2016, exchange premium increases were below projections. In 2017, they have risen at high rates in most states because of the end of rate protections known as “risk corridors” and “reinsurance” as well as the underfunding of “risk adjustment” in the ACA. All of these “3Rs” are permanent features of the Medicare Part D prescription drug program that Republicans support there and despise in the ACA.

These exchange problems are fixable. Yet you refuse to support them and fix the problems because that would undermine your case for ACA repeal.

These are my top five questions right now. Any answers, my friends?

John E. McDonough is a professor of public health practice at the Harvard TH Chan School of Public Health. He blogs at healthstew.com.