Congress made swift progress toward repealing the Affordable Care Act this month, but then President-elect Donald Trump tossed in a monkey wrench.
“We’re going to have insurance for everybody,” he told the Washington Post on Sunday.
Two days later, during an interview with Axios, he dialed back to a more GOP friendly position, indicating that he at least wants “people with no money” to have health care.
That approach sounds awfully like the Obamacare system Republican leaders have been so adamant about repealing, which currently makes Medicaid available or provides tax credits to help pay for health insurance to an estimated 20 million people with incomes below various thresholds.
Trump’s earlier position this week sounds like universal or single-payer healthcare, in which the federal government finances health care for all through some combination of payroll taxes, premiums or other government funds, as is the case in Canada.
Still, the president-elect has said he wants the ACA repealed and simultaneously replaced with a new health care law. In response, many members of Congress have discussed delays and neither they nor Trump have presented a detailed alternative mechanism for ensuring coverage for all.
The current ACA coverage mechanisms — expansion of the federal-state Medicaid health insurance program for low-income people and tax credits and insurance “exchanges” in several states that sell reduced-cost policies — worked well in 2014, the first year that major components were implemented, according to a recent analysis by health economist James Marton, of Georgia State University’s Andrew Young School of Policy Studies, and several colleagues.
On average, states that expanded Medicaid under Obamacare increased their insurance coverage rate by about 7.4 percent, the researchers found. Qualifying consumers in those states also could use tax credits to buy health insurance. And tax credits under the ACA, along with the individual mandate, increased coverage rates in states that did not expand Medicaid, but only by about 3.5 percent.
The results are based on a statistical analysis of representative national survey data collected by the U.S. Census Bureau from 3 million adults. The research was published in November of last year in the Journal of Policy Analysis and Management.
Policy-makers might pay attention to those Medicaid findings. Some GOP leaders favor replacing the ACA in part with block grants to states to maintain some of that Medicaid expansion.
But such grants are finite pots of money that can run out. Currently, the federal government pays for a certain share of each state’s expenses. And with health care cost inflation at 4 percent as of three weeks ago, those expenses will grow faster than the average prices of housing clothing, and food.
Tax credits are nice if you have taxable federal income. But about a quarter of American households bring in so little money that they pay no federal income taxes, which means no credits for buying health insurance.
It looks like someone got to Trump between Sunday and Tuesday. Because his Sunday statement indicates that Trump, like us, wants to have his cake and eat it too. He fancies the trifecta: better healthcare, for more people, at a lower cost.
“No one has figured out how to do all three of those things at once,” Marton says. “We can do any two that you pick. Otherwise, it just doesn’t add up.”
The reality, health economists know, is that increasing access and reducing prices likely will hurt the quality of health care. Or increasing quality and access is going to cost more.
The procedure that has allowed Congress to fast-track the repeal process reportedly requires committees to craft their legislation by next Friday, January 27. Tick-tock.