Are the ACA Marketplaces Fixable?

By Jill Zorn

dreamstime_xs_9893879.jpgAs discussed in a previous blog, the Affordable Care Act (ACA) marketplaces are struggling with lower than expected enrollment, sicker than expected customers, dwindling insurer competition and rising premiums in some regions of the country, including Connecticut.

Amidst this doom and gloom, it’s important to remember that there are still many competitive ACA marketplaces out there.  Also, a significant achievement was announced this week:  the percentage of uninsured people in the United States fell below 9% for the first time.

But there is no doubt that there are problems with the ACA marketplaces, that are likely to get worse.  So, as the title of this blog asks, ‘Are the ACA marketplaces fixable’?

It turns out that there are a range of suggestions out there.  They generally fall into two categories:

  • More carrots or sticks to get younger and healthier people to buy into the marketplaces
  • More carrots or sticks to entice insurers to compete in the marketplaces

Most of these fixes involve federal action, and almost all of them require Congressional approval.

This brings up an even more fundamental question than the query posed in the title.  The question is, ‘Do we WANT to fix them’?

When it comes to the Republican-controlled Congress, the answer to that question is clearly “no”.  As President Obama pointed out in his recent article in the Journal of the American Medical Association,

“While I have always been interested in improving the law…my administration has spent considerable time in the last several years opposing more than 60 attempts to repeal parts or all of the ACA.”

At the state level, it is clear that some of the most troubled ACA marketplaces are in states that refused to expand Medicaid and actively fought the ACA in other ways.  Here is how national health care policy reporter Noam Levey, of the LA Times opens his article, The States with the Biggest Obamacare Struggles Spent Years Undermining the Law:

“…Critics of the Affordable Care Act have redoubled claims that the health law isn’t working. 

Yet these same critics, many of them Republican politicians in red states, took steps over the last several years to undermine the 2010 law and fuel the current turmoil in their insurance markets. 

Among other things, they blocked expansion of Medicaid coverage for the poor, erected barriers to enrollment and refused to move health plans into the Obamacare marketplaces, a key step to bringing in healthier consumers.

Those decisions left the marketplaces in many red states with poorer, sicker customers than they otherwise might have had.”

In summary, one of the favorite sports of opponents of the ACA is do everything they can to damage it, and then say, “we told you so”, when things go wrong.

Then there are the people at the opposite end of the political spectrum that can’t keep from saying, “we told you so”, either.  They never believed a competitive marketplace composed mainly of private, for-profit insurers was the way to ensure access to health care.  They’re ready to throw the whole thing out and start fresh with a single-payer approach or, as Bernie Sanders calls it, Medicare for All.

As Robert Reich recently wrote in his Huffington Post piece, Why a Single-Payer Health Care System is Inevitable, “The problem lies…in the structure of private markets for health insurance which creates powerful incentives to avoid sick people and attract healthy ones.”  Any attempts to fix the ACA are just “band aids”.  Sooner or later we must choose, “a government run single-payer system – such as is in place in almost every other advanced economy – dedicated to lower premiums and better care for everyone.”

During the effort to pass the ACA, many supporters of single payer decided to bow to political realities, hold their noses, and fight for the ACA.  But even if the Democrats win the presidency and both houses of Congress in November, it’s not clear that this important part of their base will be willing to fight for incremental changes to a system they don’t believe is morally or practically the answer.

This leaves people purchasing insurance on the ACA exchanges in an untenable position.  With the right continuing to try to kill the ACA marketplaces and the left, even if they had sufficient political power, lacking the enthusiasm to go all out to save them, it’s unclear where those relying on the ACA for health coverage will be able to turn.

The next blog in this series will dig into some of the proposed fixes to the ACA and whether any of them could possibly move forward, particularly at the state level.

To learn more

For an interesting discussion of the politics of fixing the ACA, listen to this episode of Vox’s The Weeds podcast, particularly the part of the discussion that starts around minute 29 and goes to about minute 46.

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