Four ways states can leverage ACA sabotage

Sabotage of the ACA by the Trump administration and the Republican Congress will partially reverse the ACA's coverage gains, causing hardship to millions. But it differs from Republicans' failed legislative repeal in a fundamental way: The ACA's funding streams and mechanisms remain in place.

Not only can states that retain the will to make the ACA work continue to tap federal funding -- if they're willing to be creative, they can tap revenue streams created and inflated by the sabotage. Each form of sabotage has created new opportunities. There are at least four ways that states can not only fight off sabotage, but leverage funding opportunities that sabotage has created.

Medicaid outperforms marketplace in Kaiser probe of low income ACA beneficiaries

The Kaiser Family Foundation conducted focus groups of low income people newly insured by the ACA. Participants qualified either for Medicaid or for subsidized marketplace plans with Cost Sharing Reduction subsidies -- if they chose silver level plans, which some didn't. There were nine focus groups in six cities, convened early this year. Conclusions, in brief:

1. Medicaid enrollees were pleased, grateful and relieved to have the coverage -- though some were disappointed that the coverage did not relieve them of existing medical debt. They found the cost structure (no premium, modest copays) appropriate.

2. Marketplace coverage is better than nothing. Many used it to access medical care that they had long denied themselves; many found it more affordable than their past options. For some it was a Godsend. But...many were confused by the array of choices and complexity of terms; sorely stretched by either the out-of-pocket costs or the premiums or both; and tortured and terrified by balance billing or otherwise uncovered costs.

3. Many are sorely in need of dental and visual coverage that the plans (including Medicaid in many places) don't provide.

The results and testimonials clarified and reinforced several impressions and emerging (if still malleable) convictions of mine about our healthcare system generally and the ACA specifically. Here they are, illustrated by select comments from the Kaiser focus group participants.

Hillary Clinton "waives through" the public option

[Update: more on "BHP for all," with New York as model, on healthinsurance.org, here.]

Hillary Clinton has updated her package of proposals for "building on" the Affordable Care Act, finding incremental ways to make coverage more affordable. The new proposals include this:

Continue to support a “public option”—and work to build on the Affordable Care Act to make it possible. As she did in her 2008 campaign health plan, and consistently since then, Hillary supports a “public option” to reduce costs and broaden the choices of insurance coverage for every American. To make immediate progress toward that goal, Hillary will work with interested governors, using current flexibility under the Affordable Care Act, to empower states to establish a public option choice.

Clinton is here suggesting that her HHS will support state initiatives to form their own public options. In a vague way, she references the ACA's Section 1332 "innovation waivers" enabling states to propose alternative schemes to the core ACA structure that would meet the ACA's coverage and affordability standards. The great advantage of this proposal -- as with Clinton's promise to ramp up healthcare antitrust enforcement -- is that it would not require legislation.

As Kaiser's Larry Levitt has pointed out to me, "Nothing in the ACA stands in the way of a state creating a public option." He further noted that a state would not need an innovation waiver to form one. It would, however, need funding, and that's where the waiver might come in. If the state could find other means of savings, those measures might be integrated in a waiver proposal with a public option.