By Julie Appleby September 4,
2019
While
many Capitol Hill Republicans want to avoid a repeat of the Affordable Care Act
repeal debate, President Donald Trump keeps promising a health plan that will
be “phenomenal” and make the
GOP “the party of health care.”
Last
month, Medicare chief Seema Verma said, “We’re actively
engaged in conversations” on what to do. Earlier in August, Trump adviser
Kellyanne Conway indicated an announcement might come this month.
Behind
the pronouncements lies a conundrum: whether to
stray beyond efforts underway to improve the nation’s health care system —
loosening insurance regulations, talking about drug prices, expanding tax-free
health savings accounts — to develop an overarching plan.
For the
White House, it’s a fraught decision.
A
comprehensive plan could be a lightning rod for opponents. Conversely, not
having a plan for replacing some of the most popular parts of Obamacare — such
as its coverage protections for people with preexisting medical conditions —
could leave the GOP flat-footed if an administration-supported lawsuit before
the 5th Circuit Court of Appeals invalidates the sweeping health law.
“This
is a real conundrum. There is a risk with action or inaction,” said Dean Rosen,
a Washington, D.C., health policy consultant who often advises Republicans.
No
matter how the 5th Circuit rules, its decision, which could come soon, is
likely to be stayed while the issue heads to the Supreme Court. Such a delay
would give the administration time to flesh out a proposal if the appeals
judges throw out the ACA, but it would also ensure that a health care debate is
front and center during the presidential campaign.
Right
now, polls show the public is focused on health costs, said professor Robert
Blendon, who directs the Harvard Opinion Research Program, which studies public
knowledge of health care and policy issues. Consumers are concerned about what
they pay at the pharmacy counter or the sum of their insurance premiums and
deductibles.
“Most
voters are not interested in another debate on a new health plan,” he said.
But if
the 5th Circuit upholds a Texas ruling overturning the entire ACA, “that
changes the entire framework,” said Blendon. “The administration could not just
say, ‘Oh, we’ll have something great.’ They would have to have something
outlined.”
Supporters
and critics say likely elements are already in plain sight, both in executive
actions and proposals in the president’s budget as well as a little-noticed
white paper released late last year.
The
president has won praise from both conservatives and liberals for such things
as his proposals to require hospitals to post their actual, negotiated prices,
and some strategies to lower drug prices. But legal battles within the health
industry could thwart such initiatives.
On
these topics, “a lot of what they’ve proposed has been pretty smart,” said
Shawn Gremminger, senior director of federal relations at the liberal Families
USA advocacy group.
Still,
Gremminger points to other administration actions — loosening rules on health
insurers to allow sales of what critics call “junk” insurance because they
don’t have all the consumer protections of ACA policies, or promoting work
requirements for Medicaid recipients — as strong hints to what might be in any
eventual election-related plan.
“I
think what we’ll see is a lot of that same sort of stuff, warmed over and put
into a new package,” Gremminger said. “We fully expect it will include a lot of
really terrible ideas.”
For
other policy clues, some advisers, like Brian Blase, a former special assistant
to the president at the National Economic Council, said look no further than
that little-noticed 2018 interagency report.
The
114-page document includes more
than two dozen recommendations that broadly focus on loosening federal and
state regulations, limiting hospital and insurer market power and prompting
patients to be more price-conscious shoppers.
Many
are long-standing Republican free-market favorites, such as increasing the use
of health savings accounts, which allow consumers to set aside money, tax-free,
to cover medical expenses. Other ideas are not typically associated with the
GOP, such as increased federal scrutiny of hospital and insurer mergers, which
have driven up prices.
The
paper also calls for less restrictive rules for the Medicare Advantage plans that
offer an alternative to the traditional fee-for-service Medicare. It would
allow the advantage program to have smaller networks of doctors and hospitals —
presumably ones that agreed to charge less.
“The
administration knows where it is going on health care,” said Blase.
If the
court strikes down the ACA, he expects the administration to release a plan
supporting “generously funded state-based, high-risk pools.”
Such pools existed in most
states before the ACA. They helped provide coverage for people with preexisting
conditions who were denied policies by insurers. But the pools were expensive,
so they often were underfunded, capped members’ benefits and yielded long
waiting lists.
Some
think the white paper is not so much a plan as a “combination of policy ideas
and political statements,” said Joe Antos at the conservative-leaning American
Enterprise Institute.
Still,
he doubts the GOP needs a comprehensive health proposal. Republicans are more
likely to gain politically by merely attacking the Democrats’ ideas, he said,
especially if the Democratic nominee backs proposals for a fully
government-funded health care system, such as the “Medicare for All” plans some
candidates support.
Republicans
will “have their own one-liners, saying they are dedicated to protecting people
with preexisting conditions. That might be enough for a lot of people,” Antos
said.
Politically,
it’s risky. While many voters don’t understand all that the ACA does, some of
its rules enjoy broad support. That’s particularly true of the protections for
people with medical problems — insurers are barred from rejecting them for
coverage or charging them more than people without such conditions.
The
Republican effort to repeal the law galvanized activists during the 2018
midterm elections and is credited with boosting Democrats to victory in many
House districts.
Analysts
on both sides expect concerns about health costs and the ACA to play a large
role again in 2020.
For
Republicans, “the risk of doing nothing potentially leaves no port in a storm
if the ACA is overturned legally,” said Rosen. “But a more limited version,
which is what most Republicans are for, is likely to be met with the same
concerns. No matter what the president says, it won’t be enough for the
Democrats.”
Opinion
poll analyst Blendon said there is an additional unknown: which Democrat will
win the nomination — and what type of coverage he or she will back.
Even as
the GOP is split on how to address health care concerns, so too are the
Democrats.
“If
they are reading the same polling data as I am, they would have serious
proposals for lowering drug and hospital costs, but not offer a national health
plan,” said Blendon.
The
Democrats’ most progressive wing, led by Sens. Bernie Sanders of Vermont and
Elizabeth Warren of Massachusetts, wants Medicare for All, which would
essentially eliminate private and job-based coverage. Recent polls have shown voters are not keen to
lose private insurance.
The
party’s center, led by former Vice President Joe Biden, wants to keep the ACA
but apply “fixes” to make insurance purchased by individuals more affordable.
“If the
Democratic nominee is running on keeping the ACA, the Republican will have to
have an alternative,” said Blendon. But, if the nominee supports Medicare for
All, he predicts simply a GOP “anti-campaign” targeting the Democrat’s idea as
unworkable, socialist or a danger to Medicare.
Julie
Appleby: jappleby@kff.org,
@Julie_Appleby
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