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December 2015 (Volume 93)
The Supreme Court’s decision in King V Burwell this past summer may turn out to be a watershed moment. The lawsuit, crafted by longtime opponents of the Affordable Care Act (ACA), challenged the federal government’s authority to offer health insurance subsidies in roughly two-thirds of the states. A decision for the plaintiffs would have crippled the law’s new private insurance marketplaces in those states, forcing millions of people to lose coverage. But the Court rejected the lawsuit, with 2 Republican appointees joining the 4-member Democratic minority.
Many experts interpreted the terse opinion by Chief Justice John Roberts as a message to his fellow conservatives. Repealing the law is fine, he seemed to say, but you’ll have to do it the old-fashioned way, by winning elections and passing legislation. For that to happen, Republicans would have to win control of the White House and both houses of Congress, overcome or eliminate the Senate’s filibuster, and coalesce around the legislation, all the while risking a political backlash from the millions of people who now get coverage through the health care law. All of these things are possible. None would be easy.
That’s why, as the prospects for total repeal fade, the more interesting question may be how the ACA’s architects and advocates will react—and whether they will start working more intently on their own ideas for reforming it. Remember, the ACA never lived up to their ideals. Many would have preferred a single-payer system—something that looked like Medicare, with the government providing the insurance directly. Others had in mind a scheme that resembled what you find in the Netherlands and Switzerland, in which highly regulated private insurers operate essentially as public utilities.
Common to these visions was the hope that all Americans would have insurance, that everybody’s insurance would be sufficient to avoid crippling medical bills, and that on the whole, health care costs would become much more manageable. Progress toward these goals under the ACA has been significant—more significant, perhaps, than most Americans realize—but it remains incomplete. Studies suggest that fewer people now face financial hardship because of medical bills, for example, but plenty still struggle.1 Health care costs are rising at historically low rates, but Americans still spend more on doctors, drugs, hospital care, and related expenses than do the citizens of any other country.
The law’s advocates understood this would happen. Tom Harkin (D-IA), the former senator and chairman of the Senate Health, Education, Labor, and Pensions Committee, famously referred to the ACA as a “starter home.” As the law becomes more entrenched, it’s natural that these architects would start to think about some repair work and upgrades. Here are 3 ideas they are likely to consider:
Like all ideas for health care reform, each of these would involve significant trade-offs. Efforts to limit out-of-pocket spending, for example, are bound to mean some combination of higher premiums and greater insurance subsidies from the government. Some experts worry that European-style negotiation with drug makers would dampen innovation.
For these reasons, each of these ideas is likely to be controversial, much as the ACA itself has been. But narrow reforms like these represent efforts to tinker with the health care law’s machinery—and to modify the existing health care system—rather than to wipe the slate clean and start over.
Author(s): Jonathan Cohn
Read on Wiley Online Library
Volume 93, Issue 4 (pages 667–670)
Published in 2015
Jonathan Cohn is senior national correspondent for The Huffington Post and the author of Sick: The Untold Story of America’s Health Care Crisis—and the People Who Pay the Price (HarperCollins Publishing, 2007). He has been a media fellow with the Kaiser Family Foundation and a senior fellow at Demos, and is currently a member of the National Academy of Social Insurance. He has also written for the The New Republic, the Atlantic, The New York Times, and Self, among other publications.
Meeting the ACA’s Goals
Health Care Reform and the American Congress
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