Andrew Sprung, guest-posting at the Incidental Economist, has reviewed an interesting little e-book that is on my to read list:
ObamaCare is a Great Mess: A View of the Affordable Care Act Without Partisan Blinders & How to Fix It. By Jed Graham. Amazon, June 2015
Mr. Graham writes that there are a couple major problems with the ACA going forward. The first is that the subsidies are not rich enough to be attractive to people who make more than 200% FPL. Secondly, the subsidies are only sufficient to cover Bronze plans with big deductibles instead of cost-sharing Silver plans with low deductibles but 15% higher premiums. Thirdly, the subsidies end too soon. While finally the plans are too costly for young people which is leading to a sicker and older risk pool than projected.
Andrew has done a good job of dismantling the second point as he has been pointing out that the vast majority of people who are eligible for cost-sharing Silver plans are buying those plans as the deductibles are far more reasonable than slightly cheaper Bronze plans.
However, the other problems have a very simple solution. Shovelling money at them. The subsidy formula could theoretically be tweaked so that slope upwards of the personal contribution at a given income level is far less, the base line plans could be reset so a Silver is 75% actuarially value where the additional actuarial value is paid for by subsidy dollars instead of individual dollars. The subsidy formula could be easily tweaked so that no family pays more than X% of their income for a QHP without regard to the income level so there is no income cliff/work disincentive at 399.99% FPL.
All of those are fairly simple tweaks that are not disruptive to the fundamental delivery of health care and health insurance to the greater population. And these are all problems where throwing money at the problem is a valid and viable solution.
We did not get these policy tweaks in PPACA because the Democrats, and more importantly, the marginal decision makers in the Democratic caucs were petrified of writing a bill with a “bad” CBO score. There was a line of thought that a “responsible” and “small” bill would help preserve a majority or at least more of the marginal district Democrats. Going bigger would have produced a better bill ( and if the bill contained more cash going out the door in 2012/2013, a slightly better economy).
In reality, Democrats who represented significantly Republican leaning districts as the country became more polarized had to count on two things to stay in office. The first was that any particular opponent was a kid-diddling goat fucker. The second was a good economy with significant wage gains. A good CBO score on a polarizing bill is about the ninety-ninth ranking aid to re-election. A “responsible” bill pandered to elite consensus without actually getting any additional people to vote for “responsible” Democrats.