Obamacare’s
future hinges on who controls Washington — and state capitals, too.
By Jonathan Cohn 08/12/2018 08:01 am ET
Health
care is on the ballot this year, in more ways than voters may realize.
Full repeal of the Affordable
Care Act remains a very real possibility if Republicans get through the midterm
elections with their congressional majorities intact. But even if the law stays
on the books, its future will depend heavily on who wields power at the state
level ― as governors, insurance commissioners and members of state
legislatures.
These
officials have always had a lot to say about the ACA’s implementation, although
they rarely get the attention they deserve. Now they have even more influence,
thanks to the ways that President Donald Trump and his allies have
battered the law over the last 18 months.
The most
recent change came from Washington early this month, when the Trump
administration made it easier for people to buy “short-term” insurance
that leaves out key benefits like mental health and prescriptions and isn’t
available to people with pre-existing conditions. The plans hare
tantalizingly low premiums, but they can expose beneficiaries to crushing medical costs ―
all while driving up the price of
more comprehensive coverage.
Short-term
policies won’t be available everywhere, because states can restrict or
even prohibit them. Some have done so already. But whether more follow will
hinge, in part, on who is making the decisions come 2019.
The
current state of play for health care is a reminder of one way that the GOP’s
war on “Obamacare” has made headway ― by giving states more control so that
access to health care in places like Georgia looks more and more different than
it does in California.
It wasn’t
supposed to be this way, at least not exactly. The idea of the ACA was to make
sure all Americans, in all states, could get health insurance, partly by
creating new, subsidized market of regulated private plans and partly by
offering Medicaid to all Americans living below or just above the poverty line.
But a
2012 Supreme Court decision made it easy for state officials to reject the Medicaid expansion and GOP
leaders in 17 states have done just that, even though the federal government
picks up nearly all of the expansion’s cost. (It’s 18 states if you include
Maine Gov. Paul LePage, who refuses
to carry out an expansion the state’s voters approved by ballot initiative.)
Republican officials in a similar, overlapping list of states have done their
best to undermine the private
insurance reforms.
Access to
health care in places like Georgia looks more and more different than it does
in California.
In Florida, a lieutenant to
Rick Scott, the governor now running for U.S. Senate, blocked enrollment
counselors from holding events in state buildings. In Georgia, insurance
commissioner Ralph Hudgens came right
out and said he and his colleagues were doing “everything in our power to be an
obstructionist.” In Iowa and Tennessee, state officials
made it easy for people to stay out of the newly reformed markets ― and enroll,
instead, in plans that don’t comply with the ACA’s standards for benefits and
open enrollment.
That last
part is important because it has directly undermined how the new system is
supposed to work. Insurers need healthy people paying into the system so that
there’s enough money to cover the high medical bills of the people with serious
health problems.
The ACA
includes provisions to make that happen, including tax credits (which make
insurance cheaper) and the individual mandate (which penalizes people who don’t
get comprehensive coverage). But in states where officials have not done their
part, enrollment among healthy people has lagged and insurers have jacked up
premiums in response ― making coverage flat-out unaffordable for some of the
people who don’t qualify for tax assistance.
Things
are likely to get worse, thanks to what Republicans in Washington have done
since Trump took over. They have passed a tax cut that effectively eliminates the individual mandate
penalty. They have slashed funding for
enrollment outreach. Now, with this latest regulatory change, they have made it
easier for people to purchase ― and then hold onto ― short-term plans that
don’t comply with the ACA’s standards.
Republican
governors like Florida’s Rick Scott did everything they could to undermine the
Affordable Care Act. If Democrats take their positions in November, it could
make a big difference in how the law’s reforms play out.
People
struggling with high premiums today will discover short-term plans are a lot
cheaper ― and many who opt for that coverage will be just fine. But the buyers
who get serious medical problems will face crippling medical bills and in many
cases, they won’t know about this exposure until it is too late, because the
companies and brokers who sell these plans are notorious for hiding limits and
exclusions in the fine print.
Worries
about these kinds of issues were very much on the minds of some of the state
officials who met in Boston a week ago, for a gathering of the National Association of Insurance
Commissioners.
“I’m
concerned that people will buy these policies, show up at the hospital for a
condition they did not expect, and discover they are not covered,” Lori Wing-Heier, director
of Alaska’s insurance division, told HuffPost. She added that her office
intended to look “very, very closely” at applications from insurers seeking to
market these plans.
Officials
in different parts of the country have already taken or are considering such
action, as a recent survey published by the Commonwealth Fund
demonstrated. Massachusetts, New York and New Jersey have more or less
prohibited short-term plans altogether. Maryland, Vermont and Hawaii have
limited them severely.
Other
states, including Colorado and Oregon, have their own, somewhat less stringent
restrictions in place, while California, Illinois and Washington are in the
process of considering new ones, according to research by Sarah Lueck of the Center
on Budget and Policy Priorities. In states like Alaska and Pennsylvania, which
don’t have strong rules in place, state officials are vowing to use what
authority they have to monitor advertising material and stop brokers from
selling these policies under false pretenses.
It is by
no means coincidental that the list of states acting aggressively to regulate
short-term plans overlaps heavily with the list of states that have tried all
along to make the ACA’s private insurance reforms work and were the first to
expand Medicaid, as well.
Medicaid
expansion initiatives are on the ballot in three deeply conservative states:
Idaho, Nebraska and Utah.
Nor is it
a coincidence that the officials saying nice things about the Trump
administration regulations come from places that have been most hostile to the
ACA all along ― places like Alabama, whose commissioner Jim Ridling admitted
the new policies offer less financial protection but defended them as covering
“people up to what they can afford.”
Opinions
on the Trump regulations and how to treat them tend to correlate with party
identification, although the relationship isn’t perfect and the differences among
officials aren’t just about partisanship anyway. They reflect some real
philosophical divides over how health insurance should work and what role
government should play in managing it.
One view
supports the basic impulse of universal health care that everybody should have
access to relatively generous coverage regardless of income or pre-existing
conditions, even if that requires more regulation, government spending and
taxes. The other view holds that less government is always preferable to more and
that ultimately, people will be better off shopping for whatever coverage
insurers see fit to offer on their own.
The
latter view dominates in the South, the Plains and parts of the Midwest, which
explains why those tend to be the states with the most dysfunctional markets
and highest numbers of uninsured residents.
But that
could change in November. Democratic gubernatorial candidates have a real shot
of replacing Republicans in Florida, Georgia, Michigan and Wisconsin. Georgia
is particularly interesting because it is one of the states that elect
insurance commissioners directly and a Democrat could take that seat, too.
Democrats
in Florida and Georgia are running on Medicaid expansion, which will not be
easy to pull off quickly if, as seems likely, Republicans are still in charge
of their state legislatures. But voter initiatives to expand Medicaid are on
the ballot in three other, deeply conservative states: Idaho, Nebraska and Utah. Put it all
together and it’s no exaggeration to say that November’s elections could mean
gaining or losing health care access for hundreds of thousands of Americans ―
and maybe even millions.
https://www.huffingtonpost.com/entry/obamacare-state-junk-insurance_us_5b6e03a1e4b0ae32af98249c?utm_source=Sailthru&utm_medium=email&utm_campaign=Issue:%202018-08-13%20Healthcare%20Dive%20%5Bissue:16618%5D&utm_term=Healthcare%20Dive
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