What the ACA replacement must have

Eight years ago when the tumultuous health care reform journey began, we couldn’t have imagined the roller-coaster ride it would take. The Affordable Care Act passing without a single Republican vote, surviving the Supreme Court ruling by the vote of a Republican-appointed judge, a disastrous roll-out of HealthCare.gov, thriving for four years with Obama’s re-election, and now its inevitable repeal with Donald Trump’s win.

So it may help to look back on what Obamacare is, where it has been successful and where it has failed for Americans.

We need health care reform because our system is broken. Much like a stool with three broken legs, too many of us have high costs, low quality, and difficult access.

Cost is our ability to pay for health services as an individual or a nation. Quality is providing good care to make our lives better. Access is our ability to have health insurance and find a doctor.

The primary goals of the ACA were to improve access and quality by getting more people insured. To do this, the ACA put in place the following strategies:

Mandates. The most disliked part of the ACA was that it forced all Americans to buy health insurance, just as we have to buy car insurance, so as to have a healthy pool of people in the insurance mix. If we didn’t buy insurance, we had to pay a penalty.

Exchanges. This was a new marketplace to buy health insurance. Originally a conservative Heritage Foundation idea, it was adopted by the Democrats, then shunned by the Republicans.

Pre-existing conditions/lifetime coverage. Before the ACA, insurance companies could deny insurance to a patient with HIV or diabetes or stop their coverage during a cancer treatment.

The 80:20 plan. Insurance companies had to spend 80 percent of the premiums for patient care or return the money.

Subsidies. Families who earn on average up to $80,000 per year and wanted to buy insurance would receive financial help from the government.

Coverage up to age 26. Young adults could stay on their parents’ plan until age 26.

Medicaid expansion. States, if they chose, could expand their Medicaid program for low-income people, with the help of significant additional federal funding.

Taxes on the rich. Those earning over $200,000 had to pay an extra 0.9 percent in Medicare taxes and 3.8 percent tax on investment income. This helped keep the Medicare Trust Fund solvent.

Fees on insurance companies and pharmaceuticals. They had to pay $10 billion to $20 billion in additional fees each year. This helped pay for the subsidies for working families to buy insurance.

While the 2,700-page law had many other provisions, these had the greatest impact. According to a new poll, voters are deeply divided over the law, but only 20 percent support the Republican strategy of trying to repeal it quickly without a replacement.

Why was Obamacare so disliked by half of America?

In part, the Republicans branded the health care law as all that was wrong with our health care system. And in part, the ACA failed to do what most Americans want — reduce the cost of health care.

I believe Americans and American businesses will sacrifice quality and even access (fewer people insured or less coverage for all) if only out-of-pocket expenses would be lowered or at least kept from rising to astronomical levels.

It is unclear what the replacement of the ACA will be, but the pendulum needs to swing to cost containment with the hope of retaining much of the improved access and quality that Obamacare brought in its brief time as a law. I believe that Trumpcare or Ryancare plans will have the same fate as Obamacare if they do not address health care costs.

As Republicans in Congress and the White House work to redesign our health care system, it is important to know what an ideal health care system would look like: One that strives for low costs, high quality and easy access.

But with where we are today, most will be willing to sacrifice quality and access to reduce the cost of care to make health care affordable. Ironically, this is what the Affordable Care Act was not able to do.

Manoj Jain is an infectious disease physician and contributor to the Washington Post and the Commercial Appeal.  He can be reached at his self-titled site, Dr. Manoj Jain

Image credit: Shutterstock.com

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