In yet another attempt to repeal and replace the Affordable Care Act, much of the GOP justification boils down to one argument: that the ACA isn’t working. Never mind that we don’t really know what constitutes a “working” health care system for Republicans.
For a while, Republicans said the ACA wasn’t working because some U.S. counties didn’t have an insurer. Today, no county is without an insurer. Then there’s the argument that ACA premiums are too high. However, the research shows that while premiums have gone up, the rise in premiums has been slower under the ACA than it was before the ACA. Other health policy experts have pointed out that average premiums dropped fairly significantly early in the ACA’s implementation, even as many people were receiving much more comprehensive and valuable health coverage.
It's true that premiums did rise — sometimes dramatically and it’s an issue that lawmakers in both parties agree needs to be addressed. But on the other hand, policy experts and lawmakers knew it would take insurers time to adjust to the ACA’s new rules and protections and settle on premium rates that matched the new marketplace. That’s why ACA designers included measures like the “risk corridor” program to protect insurers from too much loss and ensure their continued participation in the ACA. Plus, ACA subsides generally shield marketplace customers from premium hikes.
Now, the GOP argument is that block granting the health care system and handing over (dramatically reduced) funds to states is a magic panacea for all of our health care woes. It's an argument that falls apart once you remember that 19 states chose not to expand their Medicaid programs, even though nearly all of the costs of expansion were picked up by the federal government. That decision — made by state lawmakers — left millions of Americans in a completely preventable health insurance gap.
The Graham-Cassidy bill isn’t a new health care system — it’s the old health care system. (Except likely even worse since it devastates Medicaid funding.) The Graham-Cassidy plan strips American consumers of guaranteed health protections and puts coverage decisions back in the hands of the free market and the political whims of ever-changing state governments. We already did that — before the ACA. That old system delivered higher and higher uninsurance rates every year, higher premiums every year, no guarantee to basic health services, discrimination based on pre-existing conditions and bankruptcy-inducing lifetime limits. Graham-Cassidy threatens to do the same thing. It isn’t innovative; it’s a relic of the past.
The real story is that the ACA isn’t perfect, but it’s ushered in some extremely positive changes that deserve more attention and credit in the health care debate. Premium rates can’t be the only way we define success or failure in a health care system. We should also be focused on how well a health care system is working to broaden access to care, create affordability and improve health metrics. In that vein, let’s take a look at just a few recent studies on the impacts of the ACA — gains we risk losing under the GOP plan as well as under pressure of constant uncertainty coming from the White House.
- In a study published this month in Health Affairs, researchers examined data from the Urban Institute’s 2017 Health Reform Monitoring Survey to assess recent gains in coverage, access and affordability under the ACA. They found that the gains made in the early days of ACA implementation have persisted into 2017, with adults in all parts of the country, of all ages and of all income groups benefiting from gains in the U.S. insurance rate. In particular, just 10.2 percent of nonelderly U.S. adults are now uninsured, compared to nearly 41 percent before ACA implementation. Adults with low and moderate incomes experienced the greatest reductions in uninsurance. For example, among adults with family incomes at or below 138 percent of federal poverty, uninsurance decreased by more than 42 percent following ACA implementation; among adults between 139 and 399 percent of poverty, uninsurance decreased by more than 49 percent. The study also found that the share of adults without a usual source of care decreased, the share without a routine check-up in the last year decreased, and fewer adults reported unmet medical needs due to cost.
- This study, recently published in Medical Care Research and Review, analyzed credit bureau data to get a clearer picture of how the ACA Medicaid expansion impacted people’s finances. In states that decided to expand Medicaid, researchers found financial improvements as measured by: improved credit scores; reduced balances past due as a percent of total debt; reduced probability of a medical collection balance of $1,000 or more; reduced probability of having one or more recent medical bills go to a collection agency; reduction in the probability of experiencing a new negative balance of any type; and a reduced probability of a new bankruptcy filing. The study states: “This work demonstrates how the ACA Medicaid expansions have improved economic well-being of low-income Americans, which at the same time has implications for providers and payers of medical services.”
- A new study published in the journal Drug and Alcohol Dependence examined the impact of the ACA on opioid addiction treatment. (FYI: Another recent study found that the opioid overdose epidemic has become so bad in the U.S. that it’s contributed to a decline in overall life expectancy.) The ACA study analyzed data from the National Survey on Drug Use and Health on more than 4,000 people with an opioid use disorder between 2008 and 2004. The researcher found that the odds of insurance coverage increased by 72 percent for people with an opioid use disorder between 2008 and 2014. In addition, the odds of not receiving addiction treatment due to financial concerns dropped by 50 percent. After ACA implementation, the study found, the odds of receiving opioid addiction treatment increased by 158 percent, with the odds of a person’s insurance paying for the care going up by 213 percent. (The Graham-Cassidy bill would allow states to waive essential health benefits, such as substance abuse treatment.)
- A 2017 study from the Commonwealth Fund, based on data from the National Health Interview Survey and the Behavioral Risk Factor Surveillance System, found that ACA expansions decreased the probability of not receiving medical care by between 21 percent and 25 percent. It also found that gaining insurance coverage increased the probability of having a usual source of care by up to 86 percent. Before the ACA, about 47 percent of uninsured people reported they were unable to get medical care because of cost. Gaining health insurance cut that number by half.
Graham-Cassidy isn’t the future of health care — it’s not a bill informed by evidence-based ways of improving people’s health and lives. It’s a bill based on political calculations, not medical ones.
Yes, the ACA isn’t perfect. But it’s making real progress that lawmakers should be working to improve upon, not tear down. If you’d like to voice your opinion on Graham-Cassidy, the American Public Health Association has an easy-to-use template to help you reach your representatives in Congress.
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for 15 years. Follow me on Twitter — @kkrisberg.