A healthcare reform plan for Joe Biden with a Republican Senate

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If, as seems likeliest but by no means certain, we have a President Biden and a retained Republican majority in the Senate, the ACA's core programs are likely to limp along fully funded but not radically improved.

Biden had proposed major reforms to the ACA, including: 1) establishing a public option, 2) allowing those with access to affordable employer-sponsored insurance to buy in to the marketplace on a subsidized basis, 3) capping premiums for a benchmark plan at a maximum 8.5% of income, with no income cap on subsidy eligibility, 4) boosting subsidies at every income level, and 5) offering free marketplace coverage to low income people in states that refused to enact the ACA Medicaid expansion.

None of that is likely to happen. At best, Biden may be able to convince McConnell to render moot Texas v. California, the case before the Supreme Court seeking to have all or part of the ACA declared unconstitutional on patently fraudulent grounds, by either repealing the individual mandate or raising the penalty to $1. 

There's much that can be done to improve the ACA -- and the entire U.S. healthcare system -- administratively, however. And we have a blueprint -- provided by an indefatigable and aggressive reformer with administrative smarts: Elizabeth Warren.

You may recall that during the campaign, Warren jumped through some convoluted hoops to straddle the gap between Medicare for All and more incremental (though still sweeping) and swiftly achievable reform.  

To that end, she released a transitional plan for her prospective first term as president last November. What's relevant now: a sweeping set of proposed administrative actions.  They include:

On Trump's fight to uninsure people

Up now on healthinsurance.org:
Courts resist Trump's assault on benefits for immigrants and the poor - so far

Rule of law, for now

It is contingently heartening that Trump administration's most egregious and damaging attempts to restrict government-supported access to healthcare for immigrants and low income people have so far been slapped down by the courts.  That is, Medicaid work requirements in Kentucky and Arkansas, and the public charge rule, stayed nationally for now.

The counterpoints are many: these stays were all imposed by Clinton and Obama appointees; the Supreme Court could overturn all; the stayed public charge rule is still having a chilling effect, inducing immigrants to forgo vital services for their children as well as themselves; and an ideologically blinkered 5th Circuit may be on the brink of striking down or impairing the ACA - in which case its fate may depend on aged liberal justices surviving through next June.  Our institutional resilience is the sound of one hand clapping.

I have a post in progress for healthinsurance.org to this effect -- this one's a placeholder.  [update, 10/22: here it is].

Four healthcare questions for Bob Hugin

Bob Hugin, the former Celgene CEO seeking to take Democrat Bob Menendez's New Jersey Senate seat, talks a moderate game on healthcare. He promises to protect access to insurance for people with pre-existing conditions, doesn't trash-talk the Affordable Care Act, and talks up value-based payment and focusing more on prevention than treatment -- pious goals to which politicians in both parties pay tribute.

Hugin is, however, a Republican - a prominent supporter of President Trump, big donor to Paul Ryan's SuperPACs, and aspiring member of Senate Team McConnell. Many of his rather vague pronouncements about existing programs demand greater scrutiny.

Hugin focused on healthcare in a September 26 roundtable in Glen Ridge, covered by Advance Media here. Here are some followup questions reporters -- and voters - -should ask Hugin when he delivers moderate-sounding pronouncements about existing programs. Quotations are from the AM story or the short video embedded in it.

1. "I cannot envision any changes to our health system today that would not protect people with pre-existing conditions." 

ACA sabotage boomerang, type 3

Recently, I tallied the various ways that Republican sabotage of ACA programs has either backfired entirely or created means of mitigating the intended damage.

Very briefly, sabotage jacks up individual market premiums, which creates inflated federal subsidies, which can be leveraged both by individuals (via discounted bronze and gold plans) and states (via federally funded reinsurance or other innovation waiver programs). Two states, New Jersey and Vermont, have also turned effective repeal of the federal individual mandate to their advantage by creating state mandates, capturing a revenue stream while holding premiums down.

Late last week, the Washington Post's James Hohmann highlighted another form of sabotage that may also at least partially boomerang: Work requirements attached to Medicaid for "able-bodied" adults. It would be hard to find a policy more universally denounced by anyone with any professional experience or scholarly purview of Medicaid. The programs are cruel,wasteful and counterproductive; they will likely  reduce both coverage and employment. And yet...

As President Trump steps up efforts to undermine the law, from repealing the individual mandate to watering down requirements for what needs to be covered in "association health plans," the administration’s willingness to let states impose work requirements on Medicaid recipients has paradoxically given a rationale for Republicans to flip-flop on an issue where they had dug in their heels.