PCMS_Philadelphia_Medicine_Spring2017 - 26
p h i l a m e d s o c .org
The Latest GOP Proposal
Republican leaders in Congress have announced their repeal
and replace health plan.
* repeal the Affordable Care Act.
* replace its subsidies with tax credits that GOP leaders say
would help a wider set of people buy insurance, if they don't
get it from work.
* get rid of the individual mandate and the requirement that
larger employers provide health insurance to workers.
* repeal most of the ACA's taxes, starting in 2018.
* freeze funding in 2020, for the 31 states that expanded
Medicaid under the law.
AARP announced that it opposes the plan, arguing that the
bill would raise costs "for those who can least afford higher
health care, for the most part. It has also been a lifesaver for consumers with pre-existing medical conditions. Before the ACA, they
were either flat out rejected by insurance companies, or could only
get a plan that did not cover their pre-existing condition. The ACA
changed that. It guarantees that such people get affordable coverage
that meets their health needs.
The ACA also allows children to stay on their parents' health
insurance plan until the age of 26. Pennsylvania Republican
Congressman Pat Meehan of Delaware County said, "Many of the
important parts (of the ACA) are going to be retained. And in any
event, there's going to be a period of transition that's not going to
leave people out there without the essential coverage that they not
only demand, but expect."
The Individual Mandate
President Trump and many GOP members of Congress believe
that getting rid of the individual mandate, and replacing it with
expanded tax credits to help pay for premiums, would encourage
healthy young people to buy policies.
The individual mandate is a part of the current law that many
people on each side of the health care debate agree has failed. Meehan
said healthy people aren't buying insurance for a very good reason.
"They're choosing not to buy because it's far more expensive than
it ought to be for that age group." Pauly said the ACA essentially
puts a hefty tax on low risk individuals. "Those poor chumps have
to support the high risks. Seems to me to be somewhat unfair."
A few years ago, both Harry and his wife lost their good-paying
jobs with excellent benefits. Now they each work for small businesses
that don't offer benefits. Harry's blue-collar job, along with his wife's
administrative assistant position, have earned them a rung on the
middle income ladder, which turns out to be a pretty pricey position
if you're shopping for health insurance through the ACA. The couple's
Low risk individuals - the ones targeted in the individual mandate
monthly health insurance premium is $1,200. Their deductible is a
whopping $14,000 a year. That means, of course, that their insurer - who decide not to buy health insurance get penalized by the federal
doesn't pay them a penny until they pony up the cash for the first government for not signing up. But the penalty doesn't come close
to the cost of paying their health insurance premium. And they also
$14,000 in medical bills.
can get in and out of the system without any penalty. "Why would
"We're not working with a whole lot of money to cover the they sign up," Meehan asked, "when, in effect, they can sign up on
mortgage, gas and electric, the car bills - we both need one to get the way to the emergency room?" He thinks there should be a steep
to work - and the phone. The premium and the deductible help penalty for people who only get into the system when they're sick,
make our budget pretty tight."
and drop coverage as soon as they're better. The idea is an important
Harry said he and his wife recognize that health insurance is a part of the Republican leadership's repeal/replace plan.
necessity. "But I need it to cost me less money. This law is called
Dr. Snyder agrees. "The ACA's special enrollment periods have
the Affordable Care Act. I think for people like us they left out the allowed persons to purchase insurance when they need it, then
cancel it when they no longer need it. It would be much better if
Harry's dilemma is the result of a federally-powered health care the government worked to support continuous enrollment, and
engine that's not firing on all cylinders. Mark Pauly, Wharton School eliminate special enrollment periods."
professor of health care management, told Philadelphia Medicine that
"The penalty should be equal to the premium of the lowest availthe ACA is a definite improvement over the way things were before able plan," Pauly said. "That way, you might as well buy insurance,
the law. But he added that the ACA neglects middle income people because you're going to pay for it anyway. But for political reasons,
who are not getting their insurance through a job. "They're treated even under Obama, no one was willing to talk about a $6,000 penalty."
very badly. They're hit especially hard by the increases in premiums
and in the drastic reductions in the generosity in coverage."
Federally-Funded High Risk Pools
Dr. Richard Snyder, chief medical officer of Independence Blue
Pauly believes that the federal government should change the way
Cross, said Harry and his wife should be able to get a better health
care deal. "That is hardly affordable, high quality accessible health it pays for coverage of people with pre-existing conditions. He favors
high risk pools. "If your risk level is beyond a certain amount, you
care, when you have large financial barriers to getting access."
can get insurance at reasonable rates, usually somewhat higher than
the average, but not that much higher. And the difference between
But the ACA Is Just Fine for a Lot of People
what you contribute to your premiums and your claims, would be
The Affordable Care Act has worked very well for people who paid with general revenue taxation."
are 138% to 400% above the poverty line. They're getting affordable
26 Philadelphia Medicine : Spring 2017