Last week, the CBO threw buckets of cold water on the American Health Care Act.
While there are serious questions concerning the CBO’s methods and its historical accuracy (see Avik Roy’s critique), Democrats fighting to defend the ACA as it heads towards collapse celebrated; they know CBO scores have potent political weight.
The Republican response was two fold—the loudest voices want to repeal the ACA and see what happens. They’re wishing away the concerns of millions of Americans to demand a rapid march over the political cliff.
Many other Republicans (e.g., Senators from Medicaid expansion states) are quietly eying the hills. To succeed politically and substantively, the AHCA needs to preserve the ACA’s most popular features in a fiscally sustainable way while building a base of political support that lasts beyond the next election.
Here’s a path forward.
ACA’s core flaws. The ACA has two fundamental flaws—it is financially unsound and politically unstable. The ACA’s financial instability is hard-wired. Combining a weak individual mandate, community rating that strongly tilts against young people, guaranteed issue and comprehensive benefits has produced predictable results. Too many young people have concluded the ACA’s a bad deal, too many others are gaming the system and premiums/deductibles are too high for too many.
Whether the ACA is in a death spiral is debatable. Whether it’s heading that direction is not.
The ACA’s enactment added political instability to the mix.
Had common ground with Republicans been found when the ACA was enacted, its repeal would not be today’s top legislative priority.
AHCA’s proposed fix; heat and light
The AHCA carries a heavy load of political peril. The AHCA replaces subsidies with refundable tax credits. Critics on the left believe the tax credits won’t be generous enough. Refundable tax credits give the Freedom Caucus real heartburn.
Eight years ago it was Democrats who were criticizing the Congressional Budget Office. Now it’s Republicans who are bashing the CBO for estimating that 14 million Americans will lose their health insurance next year if the House Republicans’ “repeal and replace” bill becomes law.
The moment that an accreditation team shows up unannounced can spike the pulse of even the most seasoned hospital executive. The next several days will amount to one big exam for the safety and quality of care, as surveyors meet with executives, managers and care teams, and watch first-hand as care is delivered. Make the wrong move or give a wrong answer, have them see rust on a ceiling sprinkler, and your hospital may get dinged. Get dinged too many times or have findings of serious patient risks, and your accreditation (and the federal funds attached to that) may be in jeopardy.
Imagine you are a doctor running a clinic in a primarily lower-income neighborhood, where many of your patients are recent immigrants from different parts of the world. You are granted a fixed annual budget of $100,000 through your local public health department, and it is unlikely that you can obtain additional funding later in the year. Traditionally, you have used your entire budget for the past several years, which usually lasts from January until December. This allows you to care for all of the few thousand patients who come to you for treatment throughout the year.
