Wednesday, September 05, 2018

Bring back the PPACA!

A reader writes: 
It is two years out [from Trump's election] and every major press outlet uses "Obamacare." That just polarizes things.

They should have come up with a better name than Affordable Care Act. That does not even capture modified community ratings – guaranteed issue –essential benefits – private enterprise (the  Republican plan). This is why Medicare for All getting better polling. 
My first thought was, imagine trying to get across "guaranteed issue,"  "modified community ratings" and "essential health benefits" in a bill title. Then a near-forgotten set of syllables popped into my head: the Patient Protection and Affordable Care Act (PPACA). "Patient protection," of course, is all about guaranteeing access to comprehensive coverage to all who want it -- including people with pre-existing conditions, who constitute somewhere between a fifth and half the population.

Nancy Pelosi famously/infamously said "we have to pass the bill so that you can find out what's in it," and people do understand and like the protections for people with pre-existing conditions. A Kaiser Family Foundation poll released today makes that clear:
KFF polling continues to find pre-existing conditions as a widespread concern and with the impending lawsuit Texas v. United States, a majority of the public say it is “very important” that the Affordable Care Act’s (ACA) protections for people with pre-existing conditions ensuring guaranteed coverage (75 percent) and community rating (72 percent) remain law. About half (52 percent) of the public are “very worried” that they or someone in their family will have to pay more for health insurance and four in ten (41 percent) are “very worried” they will lose their coverage if the Supreme Court overturns these protections.
81% of voters rate health care either the most important issue in the upcoming election (27%) or "very important" (54%).

The Trump administration may have put a sword over the heads of millions of people who depend on PPACA protections when it offered partial support to the ridiculous lawsuit filed by twenty red-state attorneys general and governors seeking to declare the ACA unconstitutional because the individual mandate penalty has been zeroed out. But in so doing, they also handed Democrats a sword in the upcoming elections.

The suit's argument in brief: The Supreme Court saved the individual mandate in 2012 on grounds that it was a tax, and within Congress's powers of taxation.  It's no longer a tax, so it's unconstitutional. And as ACA defenders argued in 2012, guaranteed issue/community rating can't work without a mandate -- never mind that Congress zeroed out the mandate without repealing those provisions or the law as a whole. The Trump administration declined to defend the law against this suit, but argued that only the ACA (oops, I mean PPACA) provisions establishing guaranteed issue and community rating should be struck down.

The Republican plaintiffs in the suit -- 18 state attorneys general and two governors -- take that as a fallback position. And their two-step position, as stated below, encapsulates actually Republican policy of the past two (or eight) years, as expressed in last year's repeal bills and the Trump administration's embrace of medically underwritten short-term plans.
The Republican attorneys general say they still believe the entire law should be invalidated, but if that does not happen, they would accept the elimination of the preexisting condition protections.
Recognizing how politically toxic their de facto drive to kill the (PP)ACA's patient protections is, Republican senators have introduced a fig-leaf bill purporting to preserve those protections. But -- surprise! -- it allows insurers to exclude coverage for a pre-existing condition.  That would undermine the ACA's underwriting/pricing/subsidy structure, since coverage for essential health benefits --e.g., say, mental health treatment -- doesn't mean much if an insurer can exclude coverage for a given person's condition -- e.g., say, depression. Hospital coverage isn't worth much if it doesn't cover your cancer treatment.

The bill would also enable insurers to vary pricing according to gender and occupation, whereas the ACA allows variation only according to age. And in the small group market, it allows for medical underwriting of an entire group -- an employer can be charged more (or less) on the basis of the health profile of its workforce, as it could before the ACA.

The allowance of pre-existing condition exclusions in particular makes guaranteed issue "something of an illusion," as the Kaiser Family Foundation's Larry Levitt told Michael Hiltzik of the LA Times.

Republican have repeatedly thrown up policy proposals that purport to protect people with pre-existing conditions -- or undermine them just a little. That was a false promise when asserted in defense of the ACA repeal bill that passed the House last year, and it's a false promise (and premise) in the current bill. As Larry Levitt put it
Saying you support protections for people with pre-existing conditions is not necessarily the same as supporting the regulations necessary to make it a reality. The wonky details matter a lot in insurance regulation.
Voters may not follow all the wonky details. But they pretty much know that Republicans are full of shit on this front. According to a Pew poll conducted in June, 48% of voters say Democrats would do a better job on healthcare versus 32% who say Republicans would..

Long ago, "PPACA" lost out to "ACA" -- and both to "Obamacare" -- in common usage. I'm not serious about bringing the awkward longer moniker back. But one way or another, Democrats need to remind voters of the PP part -- and which party is serious about effecting it.

Update, 9/6: The ridiculous Texas v. US suit has a sympathetic judge.

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