Want to repeal the ACA without actually repealing the ACA? Gut the individual mandate.

By | 2018-01-16T09:26:31+00:00 November 18th, 2017|2 Comments

In unsurprising but equally as disappointing news, Republicans in Congress are trying yet again to take affordable health care access away from millions of their fellow Americans. Here’s what it means for you. Yet again.

Before diving into the awful numbers, let’s note what Americans actually want their representatives to do on health care. Recent polling data from the Kaiser Family Foundation find public favorability of the Affordable Care Act is going up, not down, and six out of 10 Americans think it was a good thing that Senate Republicans failed to repeal the health law. Another Kaiser poll found that 66 percent of Americans think it’s more important for Trump and Congress to stabilize the ACA rather than scrap it. Kaiser wasn’t the only pollster to find support. A Politico/Morning Consult poll found just 36 percent of voters want the ACA repealed without a replacement; 50 percent oppose a repeal. A CBS poll found that a majority of Americans disapprove of the latest replacement proposal, the Graham-Cassidy bill, including 20 percent of Republican voters. Meanwhile, this year’s ACA open enrollment period (which ends Dec. 15, visit healthcare.gov for info) is clocking record sign-ups.

Anyone who thinks the ACA has been a “disaster” for the American people hasn’t actually been listening to the American people. Nevertheless, the GOP tax cut bill now being considered in the Senate pays for its giant corporate tax cut, in part, by getting rid of the ACA’s individual mandate. Republicans are hoping that without the penalty-enforced mandate, fewer people will seek out health care, which means paying out less in federal insurance subsidies and less in Medicaid and CHIP dollars. According to the Congressional Budget Office, eliminating the individual mandate will also spike insurance premiums, narrow access to affordable care and add millions to the uninsured rolls.

That’s because lots of the people who do drop out of the new health care market will be the fairly healthy ones, making it more difficult and more expensive for insurers to keep covering pre-existing health conditions, offering a comprehensive set of essential health benefits, and abiding by prohibitions on lifetime limits. Without a balanced risk pool, those expenses will drive insurers away from the ACA marketplace. That’s why the individual mandate is the heart of the ACA — it’s the very mechanism that makes those benefits feasible, possible and sustainable (at least under a system in which we’re still allowing for-profit insurance companies to act as gatekeepers into the health care system). If Republicans wanted to repeal the ACA without actually repealing the ACA, gutting the individual mandate is a good way to do it.

CBO, as well as staff from the Joint Committee on Taxation, predict that if the individual mandate is eliminated in 2019, it would decrease the number of people with health insurance by 4 million in 2019 and 13 million in 2027. Its elimination would also cause premiums in the nongroup market to increase by about 10 percent in most years of the decade. The report states: “Those effects would occur mainly because healthier people would be less likely to obtain insurance and because, especially in the nongroup market, the resulting increases in premiums would cause more people to not purchase insurance.” CBO estimated that without the individual mandate, federal budgets would decline by about $338 billion between 2018 and 2027. But keep in mind that those savings will come at a cost, namely people’s health, well-being and ability to access complicated, often life-saving medical care without facing financial ruin. The millions of newly uninsured will still get sick; they just won’t have the insurance to cover the care.

Because scrapping the individual mandate raises premiums, the Center for American Progress calculates that such a premium increase would mean an extra $1,990 for a benchmark health insurance plan for an unsubsidized middle-class family of four. Depending on the state, the 10 percent premium hike could raise family costs even more — by $2,900 in Alaska, $2,350 in Maine and by just more than $2000 in Arizona.

Republicans seem to claim that none of this really matters because eliminating the individuals mandate frees people from the burden of buying or being penalized for insurance they didn’t even want. Tara Straw at the Center on Budget and Policy Priorities puts that argument into greater context:

Republicans’ argument that these coverage losses aren’t harmful because they are “voluntary” is deeply mistaken. Regardless of why they lose coverage, those who would become uninsured would suffer harm. People without health insurance lack access to preventive care, are less likely to receive needed care, and have worse health outcomes. They also face huge financial risks, including the possibility of medical bankruptcy if they become seriously ill and need treatment.

What’s more, many of the coverage losses that result from repealing the mandate would occur because the mandate serves an important outreach function: it leads uninsured people who don’t realize that they’re eligible for marketplace subsidies or Medicaid to explore their options and enroll. Coverage losses that come because people never learn about programs or financial assistance for which they’re eligible aren’t “voluntary” in any meaningful sense.

Beyond the advocates in Washington, D.C., the actual health care sector also thinks the GOP tax cut/ACA repeal is a bad idea. In a Nov. 14 letter to leaders of the House and Senate, insurance companies, health care organizations and hospitals jointly came together in opposition to eliminating the individual mandate. The letter — whose signatories include the American Medical Association, America’s Health Insurance Plans, Blue Cross Blue Shield Association and the American Hospital Association — reads:

Experts agree that in order to have a health insurance system in which anyone can obtain coverage regardless of their health status, there must be incentives for everyone to enroll in and maintain coverage throughout the year. Broad and sustained enrollment contributes to affordable coverage as costs are shared across a larger pool of individuals. Repealing the individual mandate without a workable alternative will reduce enrollment, further destabilizing an already fragile individual and small group health insurance market on which more than 10 million Americans rely.

And finally the most important impact of gutting the ACA’s individual mandate and spiking the rolls of uninsured comes in the form of preventable human suffering and premature death. The science on this is loud and clear: having health insurance is associated with better health. We’ve already written about this, but here are a few reminders. A 2009 study published in the American Journal of Public Health found that even after adjusting for variables such as income, education, smoking and exercise, people without insurance were more likely to die than people with health insurance. Specifically, the researchers found that lack of health insurance is associated with nearly 45,000 deaths each year in the U.S. Another study published in 2014 in Annals of Internal Medicine examined changes in mortality in Massachusetts after the state implemented its 2006 health reform law. That study found a “significant” decrease in all-cause mortality as well as a decrease in deaths due to reasons that medical care has the ability to address.

In an article published earlier this year in the New England Journal of Medicine, researchers who reviewed and synthesized current literature on the associations between health insurance and health eloquently wrote:

One question experts are commonly asked is how the ACA — or its repeal — will affect health and mortality. The body of evidence summarized here indicates that coverage expansions significantly increase patients’ access to care and use of preventive care, primary care, chronic illness treatment, medications, and surgery. These increases appear to produce significant, multifaceted, and nuanced benefits to health. Some benefits may manifest in earlier detection of disease, some in better medication adherence and management of chronic conditions, and some in the psychological well-being born of knowing one can afford care when one gets sick. Such modest but cumulative changes — which one of us has called “the heroism of incremental care” — may not occur for everyone and may not happen quickly. But the evidence suggests that they do occur, and that some of these changes will ultimately help tens of thousands of people live longer lives. Conversely, the data suggest that policies that reduce coverage will produce significant harms to health, particularly among people with lower incomes and chronic conditions.

If you’d like to voice your opinion on the current tax cut/ACA legislation in the Senate, the American Public Health Association has an easy template to help you do so. And don’t forget, the ACA is still the law of the land, with this year’s open enrollment period ending Dec. 15. Visit www.healthcare.gov for information or https://localhelp.healthcare.gov/#/ to get help purchasing coverage.

About the Author:

Kim Krisberg
Kim Krisberg is a freelance public health reporter living in Austin, Texas, and has been writing about public health for more than 15 years. Follow me on Twitter — @kkrisberg — or send me story ideas at kkrisberg@yahoo.com.

2 Comments

  1. […] bill and/or the version the Senate’s poised to vote on within the next few days, including a repeal of the individual mandate that would leave 13 million fewer people with health insurance in 2027, tuition-benefit changes […]

  2. […] bill and/or the version the Senate’s poised to vote on within the next few days, including a repeal of the individual mandate that would leave 13 million fewer people with health insurance in 2027, tuition-benefit changes […]

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