Wednesday, January 6, 2016

qotd: Jost and Pollack’s proposals to strengthen ACA

The Century Foundation
December 15, 2015
Key Proposals to Strengthen the Affordable Care Act
By Timothy Stoltzfus Jost and Harold Pollack

The ACA undertook from the beginning an ambitious reform agenda, but
some of its approaches have turned out to be ineffective, poorly
targeted, or not ambitious enough to address deeply rooted problems.

Many of the remaining challenges in health care reform reflect the
inherent complexities and path-dependency of the American system and
were beyond the reach of any politically feasible reform. Perhaps the
most serious problem — which this report will address repeatedly — is
the inadequacy of the ACA's subsidies and regulatory structures to
address the problems of low-income Americans, for whom merely meeting
the costs of day-to-day essentials is a continuing challenge, and for
whom even modest monthly insurance premiums and cost-sharing are often
serious barriers to health coverage and care.

This report identifies problems and suggests potential solutions. Some
solutions would require federal legislation. Others could be implemented
by the administration, state law, or by private parties.

In all, we propose nineteen steps that could help fix recognized flaws
in the ACA as well as build on its accomplishments. Taken together,
these proposals would further improve the access and affordability of
health care under the ACA, create more robust provider networks, enhance
competition among insurers, improve the consumer experience, and
strengthen the Medicaid program. We understand that in the current
political climate, improvements to the ACA that require congressional
action are unlikely.

1. Expanding Access to Health Coverage for Moderate-Income Americans

* Fix the Family Glitch.

* Reduce Complexity in the Tax Credit Program.

* Increase Credits for Moderate- and Middle-Income Families.

2. Making Health Care Affordable

* Reduce Cost-sharing and Out-of-Pocket Limits and Improve Minimum
Employer Coverage Requirements.

* Increase Use of Health Savings Accounts for Moderate-Income Americans.

* Allow Use of Health Reimbursement Accounts to Purchase Health Insurance.

* Incorporate Value-based Insurance Design to Support Coverage for
High-Value Services.

* Improve State Regulation of Network and Formulary Adequacy.

* Improve Protection from Balance Billing.

3. Improving the Consumer Marketplace Experience

* Actively Guide Consumers in Coverage Selection.

* Improve Network and Formulary Transparency.

* Standardize Insurance Products.

4. Improving Medicaid for Low-Income Americans

* Have the Federal Government Permanently Assume the Entire Cost of the
Medicaid Expansion Population.

* Constrain 1115 Waivers.

* Eliminate Medicaid Estate Recoveries from the Expansion Population.

* Improve Medicaid Payment Rates.

* Ensure a Judicially Enforceable Right to Adequate Access to Medicaid
Providers and to Adequate Medicaid Payment Rates.

* Reconsider a "Public Option" Early Medicare Coverage within Health
Insurance Marketplaces.

* Raise or Eliminate Medicaid and Supplemental Security Income Asset
Limits for People Living with Disabilities.

From the Conclusion

This report offers a number of proposals for building on the ACA, to
make health coverage and health care even more affordable, accessible,
and understandable for Americans. We understand that in the current
political climate, improvements to the ACA that require congressional
action are unlikely. Yet an administration committed to improving access
could take some of the actions we recommend without new legislation,
while other proposals could be implemented by the states, marketplace,
or simply by insurers.


Comment by Don McCanne

Congress is divided on what to do about our expensive but highly
dysfunctional health care system. Congressional opponents of the
Affordable Care Act (ACA) today will vote for the 62nd time to repeal
the Act without offering any replacement, and President Obama will veto
the legislation. In contrast, supporters of health care reform would
like to improve the system so that it works better for everyone.

There are two approaches to improving the system: either build on ACA
and the existing financing system, or replace it with a single payer
system. Today's report is by two highly respected professors who are
personally dedicated to health care justice - Timothy Stoltzfus Jost and
Harold Pollack - and they would build on ACA. Thus today's report
represents the best of the "repair and improve" approach.

Take a close look at the nineteen recommendations by these two revered
individuals who really care about our health care system, and then think
about what impact these recommendations would have. Most of the them
would hardly qualify as tweaks, though several of them would certainly
be beneficial if we were to support the perpetuation of the current
system. But what they do not do is to provide a new financing
infrastructure that we would need to improve efficiency, equity,
universality, access, quality, comprehensiveness, affordability,
portability, and to reduce the administrative burden through public
administration - features of a single payer national health program.

We can be thankful that we have individuals like Timothy Jost and Harold
Pollack who have dedicated themselves to improve what we have. Until we
can enact a single payer system, we need their efforts to continue. Yet
they concede that "improvements to the ACA that require congressional
action are unlikely." That is the same reason given for not advocating
for a single payer system - it supposedly is not politically feasible.
But you don't compromise policy for politics. You change politics so
that you can achieve optimal policy.

Unfortunately Harold Pollack has a problem with PNHP. He has written, "I
happen to dislike PNHP leaders' unhelpful stance in the current debate,"
and "I wish the group would talk and act rather differently in this
debate," and "Indeed its leaders denigrate important provisions of ACA
that expand access for 32 million people and protect millions against
catastrophic financial risks." In fact, we have supported the beneficial
gains of ACA as important transitional improvements until we can move
the political process to achieve single payer. This matters because this
abrasiveness has reduced the framing to incremental changes or nothing,
when the framing should be incremental changes or single payer.

From the list in this report, the proposed incremental changes are far
too feeble when compared to the need. I feel certain that Timothy Jost
would be on board if there were a politically feasible path to single
payer. I just wish Harold Pollack would join us as well.

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