In a few hours, the BFD that is the Affordable Care Act turns eleven. Like many eleven years, it is gangly and occasionally awkward as it is changing and beginning to mature.
The ACA individual marketplace is entering its fourth phase. The first phase was pre-implementation and infrastructure construction. The second phase was the Obama Administration roll-out and implementation where the dueling priorities of keeping insurers on board and getting people covered in a politically acceptable manner (grandmother plans notably) were often in conflict. The third phase was schlerotic neglect by the Trump Administration along with a deep misunderstanding of the impact of CSR termination. The fourth phase is now. It is the significant expansion of affordability and a likely aggressive administrative agenda that links the ARA subsidy expansion with changes in consumer fritctions. These will be some of the first major legislative corrections and improvements that expand coverage and affordability.
I think that the big push over the next couple of years will be smoothing out the administrative frictions and choice complexity of the exchanges. The choice environment is tough. There are a lot of steps that can be taken to make choices easier and better. I think smarter defaults that strive to never expose people to strictly dominated plan choices would be a good start. After that, linking administrative records such as tax records and unemployment applications to the exchanges for automatic determination of eligibility for Medicaid or exchange coverage would be a nice next step. I also think that stronger “meaningful difference” regulation would curate the choice set to a more managable array. Actions that reduce the number of steps and the complexity of calculations that people need to either implicitly or explicitly make will improve the exchanges.
Even more importantly, Medicaid Expansion has survived the Supreme Court. Last night, Wyoming took the first step (of many) on the path to accepting Expansion. This step is partially motivated by the ARA promising to effectively pay current non-expansion states to expand Medicaid for the next two years by increasing the Legacy Medicaid match rate by 5% points. Legacy Medicaid is much bigger funding wise then Expansion Medicaid, so states that have not expanded will see net new revenues coming in greater than their 10% share match for Expansion going out.
We know that health insurance has significant mortality effects.
We know that health insurance has significant morbidity effects.
We know that health insurance has significant mental health effects.
We know that health insurance has significant financial stability effects.
The past decade has been spent building a foundation and occasionally pushing against the walls to hold them up. The next decade will be spent building on that foundation and improving a convoluted kludge of a system.
Baud
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Cheryl Rofer
Happy birthday, ACA! ?
Cermet
President Obama’s legacy lives on
Luthe
Happy birthday ACA ?? and a hearty “Fuck you!” to Joe Lieberman ?
cain
I hope we get a chance to heal the ACA from all the attacks the GOP has done on it.
mrmoshpotato
What do we get affordable healthcare and patient protections for their 11th birthday?
cmorenc
The reason the GOP fought so hard against the ACA back in 2009-2010 was, just as with Medicare and Social Security, programs that broadly benefit and provide a safety net for the middle class quickly become forbiddingly difficult to uproot and eradicate, counter to their preferred vision of a minimalist federal government outside of defense and select types of interstate infrastructure (e.g. the interstate highway system). Even with the most conservative-dominated a Supreme Court since early New Deal times in the 1930s and an Administration deliberately trying to undermine and sabotage continued implementation of the ACA, they were unable to uproot the ACA during “other guy’s” Administration.
stinger
Thank you, David. You make me hopeful.
schrodingers_cat
@cain: The Roses and their patron saint have been relentless too. D Presidents are attacked by their left flank and RWNJs no matter what they do.
topclimber
@schrodingers_cat: Such attacks upset the more conventional leftists among us, but please explain how they have hurt the ACA. I can see a case for hurting Dems in 2010, but no way the ACA did anything but win us votes after 2012.
I suggest to you that those ponies too pure for ACA have perhaps unintentionally worked in harness to pave the path to a public option in the near future. And by raising the dread prospect/s of M4A they will make improved Obamacare more attractive to moderates as the path to universal health care.
I am not faulting your disdain for the Rose-istas, but honestly hope you see how irrelevant they are. They can help torpedo a Neera Tanden, but what else they got?
L85NJGT
@cmorenc:
Support for Medicaid expansion polls at 70% in Texas. I’m not sure why GOP state leges are choosing this hill to die on – just pass it and get back to demagoguing guns, coal, and trans rights.
Ken
Isn’t there still a Supreme Court case pending? IIRC the Texas suit arguing that because the penalty has been reduced to 0, it doesn’t count as a tax so the whole law should be thrown out.
rikyrah
Yeah:)
Omnes Omnibus
I will say again that the most important thing that the ACA did was to establish in law that Americans have a right to healthcare.
schrodingers_cat
@topclimber: Those attacks helped the tea party Rs to defeat the Ds in 2010. Purity left helps Rs.