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Week 4 - Affordable Care Act - Replace

The Affordable Care Act (ACA, or "Obamacare") changed healthcare in many ways. Since its inception and introduction by President Obama, Republicans have been opposed to it for strategic and policy reasons. The oft-repeated goal has been to "repeal and replace" it. Last week, we detailed the goal - and challenges - of repealing Obamacare. The "replace" component is equally important, particularly since repeal is already beginning.


Replacement Option #1 - Revise and Rebrand
Republicans have yet to advance a plan that is both fully-developed and broadly-supported, for various reasons. This has led to speculation that the challenges of passing a comprehensive replacement may lead them to focus on revising objectionable elements of Obamacare, such as the individual mandate. With some adjustments, a program re-branded as "Trumpcare" could be presented as a replacement, possibly with Democratic support.


Replacement Option #2 - Empowering Patients First Act
Rep. Tom Price (GA-06) was nominated to be the Health and Human Services Secretary. While in Congress, he has repeatedly introduced the Empowering Patients First Act as and Obamacare replacement option. Once confirmed as Secretary, he will be a key player in the replacement process, likely drawing from that Act. Among other elements, it:

  • Repeals the expansion of Medicaid provided under Obamacare.
  • Ends the requirement for certain minimum services - the "essential health benefits," including behavioral health treatments.
  • Ends lifetime coverage limit bans.
  • Provides refundable tax credits (~$1,200 - $3,000 per person),  to help people buy their own insurance.
  • Gives states grants to provide high-risks pool or other coverage mechanisms.
  • Requires coverage for pre-existing conditions if a person had insurance for 18 months before picking a new policy.
For people with developmental disabilities, the essential health benefits provide a number of regularly-used services (like rehabilitative and habilitative services/devices). Some state protections exist (e.g., SB 946, requiring behavioral health coverage), but premiums could go up for someone who wants coverage equivalent to their current plan.

Additionally, by rolling back the Medicaid expansion, states could lose federal funds for some people's community services.


Replacement Option #3 - A Better Way
Speaker Paul Ryan, as leader of the House of Representatives, is also well-positioned to have a major role in any replacement plan. He has already drafted a proposal titled "A Better Way." However, it focuses more on goals than policy details. Among other elements, it seeks to provide for:
  • Increased consumer choice by use of health savings accounts (HSAs). 
  • Coverage for people with pre-existing conditions, with a ban on policy cancellations.
  • High-risk pools for people who are priced out of coverage.
For people with developmental disabilities (and their families), a reliance on HSAs may be of limited use. This option is based in part on the idea that people should be allowed to buy plans with higher deductibles or fewer benefits, at a lower cost. HSAs let people set aside money to pay for deductibles or other costs when treatments are needed. Critically, this assumes the individual can afford to set aside that money - possibly thousands of dollars. 

Also, like the Price plan, A Better Way proposes the rollback of the Medicaid expansion, with cost questions remaining open.



Regardless of what the replacement looks like, the tremendous tension between camps arguing for a rapid repeal and those seeking to develop a functional replacement is growing sharper by the day.
Next week, we will be look at Medicare reform proposals and how they could affect our system.
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