Thursday, October 18, 2018

In which Larry Levitt highlights the missing link in our fevered debate over preexisting conditions

This nineteen month old tweet, posted as House Republicans were poised to release the first iteration of their ACA repeal bill, made a lasting impression on me:

As the repeal attempts are re-litigated this election season (and threatened for next year if Republicans retain control of Congress),  I've noted again and again that the fight over who would protect access to insurance for people with pre-existing conditions is obscuring the more fundamental fight over government funding  for public healthcare programs -- primarily for Medicaid, but also for affordable access in the individual market.

The House Republican repeal bill (the American Health Care Act, or AHCA), as passed, would have cut $834 billion in federal Medicaid funding over ten years and another $149 billion, net of added "stability funding," from individual market subsidies, per CBO estimate. The 23 million increase in the uninsured population forecast by CBO had little to do directly with the rules concerning guaranteed issue and community rating.

That said, progressive healthcare scholars have eagerly joined the rhetorical battle over Republicans' bogus claims that they'll protect pre-ex access. None more so than the Kaiser Family Foundation's Larry Levitt, who keeps pointing out, as here, that
Insurance regulation is a bit like plumbing. A small leak tends to become a big leak over time. If there’s a loophole in the regulations, some insurer will find it and take advantage of it. That insurer will start to attract healthier enrollees, and other insurers will be forced to follow.
Point taken, and taken, and taken...but Levitt adds something in this piece that for me bridges a disconnect:
a challenge for Republicans is that making preexisting condition protections a reality requires a significant amount of government regulation, funding, or both
The key word here is "funding." Remember the three-legged stool? If you want to a) offer insurance on equal terms to people regardless of their health and medical history, you have to b) pull people in via an enforcement mechanism, and c) make coverage affordable.  The ACA is currently a two-legged stool, the mandate having been sawn off (by Republicans, natch). The AHCA sawed off most of a second leg, by replacing the ACA's income-adjusted subsidies (which are themselves inadequate) with flat subsidies that were grossly inadequate.

To get at the most egregious harm Republicans attempted in 2017, Levitt finesses a point :
Medicaid also plays a big role in covering people with preexisting conditions who have incomes below or just above the poverty level, particularly in states that have opted to expand eligibility under the ACA, providing coverage to an additional 12 million people.
The ACA Medicaid expansion, which extended Medicaid eligibility in states that opted in to adults with incomes up to 138% of the Federal Poverty Level (FPL), directly addressed only one preexisting condition: poverty or near poverty. And there's the rub. The main thrust of the Republican threat to public health is more a matter of funding than coverage rules per se (though the Medicaid work requirements that red states are now implementing uinsure people by regulatory means). So Levitt's larger point -- always hiding in plain sight in our indirect political discourse -- is this: you can't protect access for people with preexisting conditions without subsidizing coverage in a way that makes it affordable for all.

The ACA failed to make coverage affordable for all -- mainly for people with incomes above the subsidy line (400% FPL) who must rely on the individual market, but also for a fair amount who do qualify for subsidies. But the House and Senate ACA repeal bills were orders of magnitude worse in this regard. Those bills would have uninsured the majority of those who gained coverage through the Medicaid expansion, and probably most of the 50%-plus of marketplace enrollees who qualify for Cost Sharing Reduction subsidies, which the bills wiped out. (The repeal bills would have replaced some of those low income enrollees with more affluent and young enrollees for whom the flat subsidies support enough to make purchase viable).

The Republican bills would have also slow-strangled Medicaid more generally by imposing per capita caps or block-granted funding. That also has a "preexisting condition" component, as Medicaid provides vital healthcare access to the disabled and to people in nursing homes -- not to mention to nearly 40% of those with a substance abuse problem.. Again, though, that is a matter of funding, not coverage rules.

In our indirect political discourse, "preexisting conditions" is a synecdoche for affordable coverage for all. If Republicans retain control of both houses of Congress, they'll likely grow the ranks of the uninsured by over 20 million -- roughly a two-thirds increase, over ten years, and maybe by more in succeeding decades.  They'll do it mainly by defunding public programs. And yes, they'll corrupt the regulations too.

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