Friday, May 20, 2022

ACA on the rocks

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Today Politico sounded an alarm that's been rising in Democratic policy circles: Democrats are walking right into an Obamacare fiasco of their own making. That is, if their lawmaking capacity is so paralyzed that they fail to extend the major boosts to ACA marketplace subsidies provided by the American Rescue Plan Act through 2022.

Politico's Adam Cancryn and Megan Messerly warn concisely:

The scenario has alarmed vulnerable lawmakers and White House allies, who have privately warned senior Democrats in recent weeks that the issue could cost Democrats control of the Senate and decimate their hard-earned reputation as the party of health care.

Politico does report some talks between Manchin and Democratic leadership. At this point, whether ARPA subsidies get extended appears to boil down to whether Manchin and/or Sinema simply want to destroy Democrats' electoral prospects -- now, and given the Republican drive to suppress votes and doctor vote counts, maybe forever. At the Washington Post's Plum Line, Greg Sargent is doubtful that Manchin will let any meaningful legislation pass.

As the clock ticks, I feel compelled to add my popgun to the salvo of increasingly desperate progressive healthcare groups and individuals begging Democrats to find a way to break the Manchin-Sinema blockade and extend the marketplace subsidy boosts provided by the American Rescue Plan. 

Charles Gaba has documented the impact on the premiums for individuals of various ages and incomes -- most dramatically, on 60-somethings who hit the reinstated subsidy cliff. The Kaiser Family Foundation reports that absent ARPA, 2022 premiums paid by enrollees in the 33 states using would have been 53% higher. Families USA tallies the net cost to families in each state. The Urban Institute forecasts that 3.1 million people will become uninsured if the ARPA subsidy boosts expire. As for me, I have tracked the huge pandemic-era surge in enrollment in nonexpansion states, at low incomes, and at higher incomes. I even have a personal stake, as my wife and I are enrolling in marketplace coverage effective June 1. 

Beyond the specific losses in enrollment and affordability for those enrolled is integrity of Democrats' drive toward universal healthcare. Their signature bill of this century was dubbed the Affordable Care Act, but the subsidy structure was manifestly, obviously inadequate from the start. After the ARPA subsidy boosts, the marketplace remains a flawed and kludgy artifact, but in concert with the Medicaid expansion, in states that have not rejected the latter in wanton contempt for their low-income residents, it now has a credible claim to offer an affordable health plan (albeit, often with very high out-of-pocket costs and/or a narrow provider network) to any citizen or legally present noncitizen who lacks affordable access to employer-sponsored or other insurance. 

If that progress is to be undone, it should be Republicans who undo it.  That's their brand, their function in life, part and parcel with the general destruction they're poised to wreak on American society and what's left of our democracy. I want to say Democrats shouldn't help them, but they know that. The question is really whether Democrats maintain effective control of the Senate as of now.

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  1. Thanks for directing me and other readers to the convenient Gaba tables ( ).

    As you point out, they especially illustrate the dire situation for "60-somethings who hit the reinstated subsidy cliff".

    Thus, a very convenient illustration is the very last line of his table--Wyoming, pre-retirees, at $75,000 of income for a couple -- just over "the subsidy cliff".

    We can calculate, for them, a $33,000 for ACA premiums (44% of pre-tax income). Knowing the couple likely also has a $16,000 a year out of pocket maximum, we can figure out that the couple has to allow 65% of pre-tax income for premium plus possible out-of-pocket. (Not affordable!)

    The same exercise can be done, with similar results, for the other states.

    Politico, you, and others point out that this looks like a political problem, because the increase into unaffordability will be very visible to those experiencing the increases, and perhaps their friends and relatives.

    (Thus, the regrettable dumbness of the politics and the media. There is mainly perceived a problem when it is very visible and obvious. Much less obvious our Medicaid estate recovery issue for people 55+ in 20 or so states, where many people actually have no insurance at all, and can owe all medical bills that were paid out for them at death. Much less visible -- visible only in the once people die, which will often be decades from now. For completeness on this issue on which I am obsessed, the reference: )

  2. I do not know if there is any way to reach the persons who would be impacted. General appeals might not work.
    I would think that Sens Manshin and Sinema have constituents who would be impacted.