A June Health Affairs briefing on the implementation of the Patient Protection and Affordable Care Act (PPACA) showed just how deep the chasm is between many of Washington’s policy experts and ordinary Americans. At the briefing, panelists discussed the potential impact and implementation of the PPACA amidst the public’s uncertainty over the law’s provisions and the likely, as well as the unintended, consequences.
The panelists discussed three main issues: whether the PPACA would bend the cost curve, the states’ role in reforming insurance markets and the impact of Medicaid expansion on the states.
Harvard Professor David Cutler said the law could lower costs because there is so much waste in the health system. He focused on the potential for the general improvement of information technology. Following Cutler, Michael Ramlet spoke about his paper with Douglas Holtz-Eakin. They estimated that the new law will cost the government far more than projected, and that it would not, as promised, end up reducing health costs for the American worker.After the cost curve panel, Nancy Ann DeParle, director of the White House Office of Health Reform, defended the law. She relied upon a Commonwealth Fund study to project falling premiums and costs. Ms. DeParle’s figures contradict the estimates produced by both the Congressional Budget Office and the Office of the Actuary at the Centers for Medicare and Medicaid, which forecast increased health care spending and increased insurance premiums. Furthermore, analysis by the Heritage Foundation suggests the government will add about $2 trillion more to the deficit over the next 20 years.
The second panel discussed the impact of the PPACA on the states. This was supremely interesting because most of the panelists suggested that the PPACA is a triumph of federalism in action since Washington gives states flexibility to construct the federally authorized health insurance exchanges to their specifications. Len Nichols, director of George Mason University’s Center for Health Policy Research and Ethics, denied that the PPACA was a federal takeover. Nichols pointed out that a federal takeover bill is not 2,000 pages; a federal takeover bill is two lines: “You’re all in Medicare. It starts in July.”
Such a health care bill would have been politically unfeasible. Instead, Congress placed complicated provisions in the law, representing a substantial growth in federal regulation and ensuring government encroachment into the health care decisions of most Americans. The most obvious: all health insurance plans will have to meet the specifications laid out by the Secretary of Health and Human Services. Of course, while it is true the states have the option whether to form their own state health insurance exchange or opt for the federal design, the Health and Human Services Secretary is tasked with approving all state health insurance exchange proposals. Exchange design approval is only one way the HHS secretary asserts power over states.
Most panelists viewed Washington’s promise to states that funds will be available for forming exchanges or conducting insurance premium rate reviews as an extraordinary opportunity for states, especially those with budget problems. But, of course, there are strings attached to accepting federal funds. For example, if a state accepts federal funds for insurance premium rate reviews, it is required to provide information to the HHS secretary about trends in insurance premium increases. That would be a gateway for the HHS Secretary to gain more power and impose further regulation over a state’s insurance system. State officials are understandably wary of all this federal assistance, and many, if not most, share the Heritage Foundation’s very a different vision for the state health insurance exchanges: consumers would be allowed to choose their own plan based on their personal needs, not a federal prescription.
Medicaid expansion was the main topic of the last panel. More than half of the increase in insurance coverage under PPACA will be Medicaid coverage. The federal government will reimburse states at least 90 percent for coverage cost of the newly eligible enrollees, but states will receive much less federal support for individuals who decide to enroll who were eligible under the old state eligibility rules.
George Washington University Professor Leighton Ku hinted at the complexity of the new law when mentioning how “tricky” it would be to process new enrollees: “The concept really is that there is supposed to be a ‘no wrong door’ policy, that regardless of whether [enrollees] think they are applying for Medicaid, for [the Children’s Health Insurance Program], for the subsidies or the health insurance exchange,…there will be a simple application system that will somehow channel them appropriately to the right program.”
Several panelists indicated that they were perplexed that the states with the most to gain from the law are simultaneously fighting against it, joining the law suit against the mandate. According to Ku, in the states opposing the law, 39 percent of Medicaid-eligible adults are uninsured, versus only 26 percent in other states. This is another indication of the gap between Washington policy experts and state officials. State officials worry about the affordability of the federal mandates and the impact on their taxpayers. And others resent the top-down approach to health reform that is being imposed by Washington.
Beyond state officials, this gap broadens and deepens with the average worker or business owner, and among the general public where polls show support for the law is relatively low. While Washington is focused on convincing states to take federal government grants, ordinary Americans are worried about keeping existing coverage. While Washington policy experts wants to make the PPACA work, most American voters want it repealed.