Could It Be Done Through The ACA?-A Different Route To Universal Coverage


Leonard Zwelling

In The New England Journal of Medicine on May 2, Fiedler et al outline a new plan to cover the 9% of the population that is still without health insurance after the ACA was fully implemented. This article is worth consideration on one level and also a source of skepticism on another. Of course, this only matters if the current administration and its allies in Congress and the courts don’t erase the ACA as they have been trying to do.

It’s worth a look because the Dem’s only concrete proposal for eliminating the need for coverage among the 9% has been Medicare for All or something like it. This is essentially, a complete government takeover of the payment for insurance and thus the payment for health care. (But not the delivery of health care necessarily.) This idea drives Republicans to distraction because Republicans want private solutions to all problems rather than government intervention. It also drives a lot of Democrats and independents batty because they cannot get a grip on the $30 trillion price tag Bernie Sanders has put on his program over ten years. Of course, we spend that now on health care (about $3 trillion annually) and a fair amount of that is out of everyone’s pocket. The idea of insurance is to spread the risk. So either we are going to have to let everyone fend for him- or herself (as we do now) or we will admit that birth is a pre-existing condition and that everyone will get sick sometime so why not just spread the risk among all Americans? I’m in the latter camp, but do not believe there is only one way to get there.

This article derives a way that I hadn’t considered.

First it breaks the 9% (roughly 30 million people) into six groups: those below 138% of poverty line in states that have not expanded Medicaid; those eligible for tax credits in the exchanges who have not registered; those ineligible because they make over 400% of the federal poverty line, but who still need help; those in financial straits who have access to employer insurance that is still too pricey; those eligible for Medicaid or CHIP who have not enrolled; and the undocumented.

The solutions of the authors is a combination of carrots and sticks using federal money including incentivizing the expansion of Medicaid at the state level, increasing subsidies, enhancing outreach to get eligible folks on the programs designed for them, and even speeding up paths to citizenship to increase the eligibility of the undocumented who right now consume health care in emergency rooms and clinics that receive no payment for that care thus driving up the price for the rest of us.

This article is worth a read, BUT…

What the article doesn’t do is estimate the cost of such a broad program.

That’s the rub with all of the proposals to alter the health insurance market—even Bernie’s that might eliminate that market.

In the end it comes down to two decisions:

First, is access to affordable, quality health care a right of citizenship like access to the police and fire department?

Second, if it is, how do we pay for it and how much do we pay?

I think the answers are yes and it depends.

These sorts of changes cannot be made in a vacuum. Drug pricing must be considered. Provider income and medical school debt must be addressed. The elimination of the for-profit hospital and insurance sectors must be understood as potentially harsh secondary effects of such a system.

There are trade-offs everywhere and no one wants to make less money which is what makes cost reduction so hard. It will take a referee of uncommon insight to address this. Let’s call Ken Feinberg (the man who doled out the 9/11 money). Then when he finishes fixing health care in America, we can send him to the Middle East.

This article, like so many others, does a great job of outlining the problem. It even suggests some solutions. It doesn’t solve the big one. Who pays and how much?

Leonard Zwelling