As we deal with serious COVID-19 concerns, it might not hurt to pause briefly and reflect on the manufactured celebration we otherwise would have heard this month about the increasingly popular Affordable Care Act, first launched into law ten years ago on March 23, 2010.
The invitations to the tenth anniversary party already were in the mail. A serialized set of papers from a previous conference began appearing in Health Affairs late last month, with a book volume set to land on digital shelves shortly. Even I was asked to contribute a back-cover book blurb (I didn’t make it, after first offering “I laughed. I cried. It was better than Cats!”). Other signs of preliminary throat clearing were underway. And counterarguments within the health policy bubble were due to pop up soon.
Like the original political battles over the ACA, these fading replays are destined to be fought to another draw, at least depending on which echo chamber one favors. To be sure, popular opinion has shifted slightly in the ACA’s favor. However, that largely reflects an updated status quo bias, in which the law’s implemented arrangements are more familiar and seem less disruptive than any remaining vague promises to replace them someday, somehow. The legislative failures of ACA opponents in 2017 live on as lessons in unsuccessful dives off the cliffs of Acapulco as the political tide moves out.
But what did the ACA achieve, beyond its own political survival? One form or another of insurance coverage, however disappointing or mediocre, expanded, albeit at a higher cost per new enrollee that might have been efficient. Certain segments of the population, generally lower income and particularly those ones at higher predictable health risk, faced fewer barriers to coverage, but at the expense of higher costs and reduced access for others — particular those individuals who might otherwise gain coverage in the individual market who now face higher, unsubsidized premiums, greater cost sharing, and more restricted provider networks.
The ACA, on balance, was also fairly generous to the health care industry overall; particularly for the bottom lines of most hospitals, drug makers, and even insurers — or at least the still-thriving dominant incumbents in increasingly concentrated health care markets. On the other hand, those projected gains and losses turned out somewhat differently in timing and distribution, due to changes in the original law and initial expectations (or hopes) along the way.
An initial takeaway: The ACA shows that if you throw enough economic resources at loosely defined objectives, some of them will stick. Our political memories and economic calculations are less discerning in accounting for the true opportunity costs and target efficiency.
Even more overlooked by ACA advocates and detractors is that the current version is a political adaptation, in many respects, of what was first promised — or even initially enacted into law. Far grander, yet ultimately unworkable dreams had to be modified, delayed, or simply abandoned as they tried to evolve from political rhetoric and simple proposals to realistic policy and political acceptability.
The list of detours and dead ends is quite lengthy, whether due to legal challenges, administrative workarounds, creative re-interpretations, legislative modifications, or just plain “oops” abandonment. An initial scrolling includes such provisions as: the individual mandate, employer mandate, Cadillac tax, other “pay-for” taxes on the health care sector, mandatory Medicaid expansion, grandfathered and grandmothered insurance plans, co-ops, auto enrollment, IPAB, Class Act LTC benefits, open-ended risk corridor subsidies, restrictive rate review, health exchanges administered “by the state”, network adequacy standards, and enforceable contraceptive coverage mandates. The Trump administration also reshaped earlier policies involving short-term limited duration plans, association health plans, and HRAs. They also opened new “waiver” doors in states’ Medicaid and individual insurance markets.
The most significant change is the reinvention and expansion of individual insurance tax subsidies, in place of the law’s original cost-sharing-reduction subsidy payment parameters. About two and a half years ago, insurers and their regulators devised a new scheme to exploit a loophole left open by the ACA. They began substantially hiking the premiums on only the 70-percent actuarial value plans used to calculate those subsidies for all exchange plans, thereby sustaining the program through enhanced loads of other people’s money. In other words, the cushioning tide of more federal dollars lifted enough ACA boats to hide the leaky hulls lurking beneath. It particularly worked as an excellent flotation device for coverage stools lacking some original legs.
Overall, the ACA will serve as a continued example of how we continue to tolerate the chronic mediocrity of our health care system’s actual performance, because it does achieve its primary goals — hiding its real costs, shifting blame, dodging accountability, limiting competition, and keeping its main players in business to come back for more another day. So we may never get the health care we say we want, but our political system ensures that we get the health care we deserve.
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