By Mark D. Olshan
Associate Executive Vice President, B’nai B’rith International

You may have heard the story of the dog playing in the front yard of his master’s home who always ran barking after the bus that passed by until he got tired and stopped running. The next day, the same thing happened. The bus would drive by and the dog would bark and run trying to catch it. And this would go on, day after day, after day…

Well, guess what? One day, he finally caught it.

Now, what in heaven’s name will he actually do with it?

During the seven years since the passage of the Affordable Care Act (ACA), Republicans on Capitol Hill stood united in their resolute opposition to what they relabeled, derogatorily, as “Obamacare.”

Rather than accept the fact that the program could help many Americans and try to modify and improve this admittedly massive attempt to overhaul health care, making it even more affordable and workable for the American people, the goal was to deride the ACA as singlehandedly destroying health care in America.

From the moment it was enacted more than seven years ago, congressional Republicans vowed to “repeal and replace” the ACA with something “cheaper, less bureaucratic and offer far more choices.” Yet, it was only just recently that an alternative plan was finally introduced. After the plan failed to pass, House Republicans mustered a slim majority in early May, sending the measure to the U.S. Senate where it faced an uncertain outcome.

Repeal and Replace? Yes, Mr. President, It’s Complicated.

With a Republican president and his party controlling both houses of Congress, the goal of “repeal and replace” seemed within reach. But, it has been proven more difficult, especially after the nonpartisan Congressional Budget Office estimated up to 24 million Americans would lose health coverage under the Republican proposal.

Now, I don’t presume to suggest that the ACA as rolled out was perfect. There were areas that needed to be tested empirically and potentially improved. Many of us would agree that keeping our kids on our health care plans until they are 26 and better able to purchase insurance on their own are good ideas. Also, any of us with pre-existing conditions would like to have continued coverage should we move to a different insurance carrier or plan. Additionally, subsidies for persons of a certain income or facing higher age-related insurance costs are intended to guarantee acceptance into a quality insurance plan, covering an estimated 15 million to 20 million persons who would otherwise be uninsured.

But how do we pay for all this? Well, the idea was to make certain that younger, “more healthy” individuals would be enrolling, bringing in a massive infusion of dollars that would balance those older and probably more likely to require expensive health care. In essence, spread the risk around, thus keeping rates more affordable for all.

Unfortunately, many younger folks don’t think like that. I guess if you’re young and healthy, you don’t think you need to be insured because you feel that you will never need coverage. So much for that infusion of cash and young people needed to balance out the risk pool.

Obviously, this was a major sticking point in the “repeal and replace” debate. Representatives of the congressional Freedom Caucus opined that people should be responsible only for purchasing the amount and specific type of insurance they wanted. However, the suggestion that people who buy lower cost or high-deductible insurance do so because they want to, rather than because it is all they can afford, strains credulity. So much for the collective “risk pool” and understanding of how insurance actually works.

But, what about us “older” persons?  

Generally, I don’t believe most people thought that seniors would be part of the discussion on “repeal and replace” because they are already covered by Medicare. While the vast majority of Americans 65 years and older have Medicare, many older persons and people concerned about aging in America have plenty at stake in any replacement system that comes to fruition.
First, for aging to look the way it does in the best brochures—with happy retirees enjoying travel, volunteer work, long walks on the beach— we need to be healthy and still have some savings to afford this lifestyle. So, from the perspective of the long game, health care coverage is essential for making “healthy aging” a reality.

When we talk about older adults, however, we aren’t magically targeting people the day they turn 65. From 50 through 64, there is a greater likelihood of becoming disabled or developing conditions like diabetes, manageable with appropriate treatment but devastating if left untreated. Health insurance for this group has always cost more—and the loss of employer coverage many suffered during the Great Recession has only heightened the problem.

For this group, the Affordable Care Act dramatically reduced the “age tax” that insurers could impose for just being older, and it eliminated exclusions from insurance for those with pre-existing conditions. Further, the law reduced or eliminated out-of-pocket charges for preventive care. The ACA also expanded Medicaid to cover lower income older adults too poor to afford insurance—even with subsidies—but not poor enough for traditional Medicaid. Many covered by the Medicaid expansion are ages of 50 to 64.

Finally, there is a great deal in the ACA for Medicare enrollees. The replacement bill eliminated cost sharing on a whole host of preventive services that help keep older adults healthy—services some skipped in the past because of cost, with expensive results both in terms of future Medicare spending, and length and quality of life. The ACA also established a timetable for closing the “doughnut hole” that makes the cost of prescriptions through Medicare prohibitive. While the “repeal and replace” measures that were floated did not specifically repeal this fix to the coverage gap, they would have eliminated the fee on manufacturers and importers of branded prescription drugs that helps pay for the benefit.

So, What Now?

As we go forward, a word of caution: The devil is always in the details. Advocates for healthy aging, as well as older adults and people who love them, should be looking very carefully not at what alternative plans claim to do but what they actually would do.  

Recently, we’ve heard of proposals that claim to save the Medicaid expansion but would, in reality, limit it to a grandfathered group that would shrink every year as people cycle on and off Medicaid (because of fluctuating income) and fail to get alternative coverage, thereby disqualifying them from rejoining the expansion if their income drops.

In addition, we hear about sweeping changes to Medicaid. Millions of Americans are eligible for Medicare at age 65 and for Medicaid, because they have very low incomes and few assets. Currently, states get matching money based on how much they spend on Medicaid. Under various proposals, the federal government would cap its contributions to states, no longer responding to changing circumstances that affect actual state spending on the program. Thus, the federal government would save money by giving the states less, leaving the states to bear the burden. But the resulting reduction in the federal deficit is merely a shifting of the expense to the states, which can then reduce benefits, raise taxes or incur their own deficits to make up the difference. Even now, states struggle to fund their share of Medicaid.  

And finally, as it stands today, if the ACA were to be eventually repealed, those in their fifties and sixties could see premiums rise by $2,000 to $3,000 a year or more, with increases of 20 percent to 25 percent, or higher. Under the ACA, insurers cannot charge more than three times what they charge younger persons for the same coverage. This ratio was proposed to increase to five to one—or even more.

So, does the concept of “bipartisanship” still mean anything in Washington?

Perhaps it may be time to actually see where it makes sense to work “cooperatively” and “fix” certain issues of the ACA rather than continuing to tackle “repeal and replace” without any reasonable replacement.  Those on the hard right clearly want to see anything from Washington just go away. However, there are more moderates on both sides of the aisle who disagree.
Let’s try something unique in this town—building consensus, as opposed to playing politics.

Can you say, “Single payer system?”