1. Molyneux, Jacob Senior Editor


The future of public and private plans depends on a confrontation with rising costs.


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Nurses know as well as anyone that access to affordable, quality health care can be a life or death matter. Yet the most obvious characteristic of U.S. health care in recent years has been uncertainty and change. On the one hand, we've seen a remarkable 20 million-person reduction in uninsured Americans since 2010, when the Affordable Care Act (ACA) became law. On the other, consider the array of legislative efforts and lawsuits seeking to repeal or invalidate all or part of the ACA, the doubling and tripling in a few short years of premiums for some ACA marketplace plans, the state Medicaid eligibility expansions voted for by citizens and then blocked by governors or undercut by new work requirements, the extraordinary increases in costs of life-sustaining drugs like insulin and EpiPens, and the shifting of an ever-greater percentage of health care costs to employees in employer-sponsored insurance plans. And then there's the issue of Medicare solvency, recently downgraded another three years to 2026 in the wake of revenue cuts from the 2017 Republican tax plan.


Two aspects of the ACA dominated news before the midterms: threats to the law's preexisting condition consumer protections and the question of whether to expand Medicaid eligibility in individual states. Election results-in which Democrats retook the House while Republicans retained control of the Senate and three traditionally Republican states (Idaho, Nebraska, and Utah) voted to expand Medicaid eligibility-have been widely interpreted to suggest that core ACA provisions expanding consumer protections and access to health care coverage have won a measure of bipartisan public support.


This could signal a meaningful and possibly lasting shift in public expectations. In several previous elections, the Republicans were able to turn opposition to the ACA into votes by portraying the ACA, particularly its now-repealed individual mandate, as government overreach. This time, their history of opposition to the ACA may have cost at least a few members of Congress and governors their jobs.


The fact is, preexisting conditions are increasingly the norm, not the exception. According to the Centers for Medicare and Medicaid Services (CMS), between 50 and 129 million Americans have a preexisting health condition. Before the ACA, Americans with preexisting conditions (those without employer-sponsored plans or Medicare or Medicaid) were often denied coverage, offered subpar coverage at unaffordable rates, or required when starting a new job to wait a year before coverage of a preexisting condition. The ACA made all this illegal, and over the course of the past eight years, Americans have grown attached to this as the norm.


As we go to press, the future of the entire ACA remains in question: 20 Republican state attorneys general have brought a suit in a Texas district court seeking to invalidate the remaining parts of the ACA, particularly preexisting condition protections. The suit has been supported by an amicus brief filed by the Trump administration. If the suit is upheld, whether all or in part, the effects could be potentially catastrophic.


Meanwhile, with at least three new states ready to expand Medicaid eligibility, the number stands at 37. But even as hundreds of thousands more people may soon be added to Medicaid rolls, several Republican-led states have recently sought and been granted waivers from the CMS to add work and reporting requirements for a percentage of Medicaid beneficiaries. Justified by a stated wish to empower individuals by returning them to the workplace, this strategy's results so far appear to be a sharp reduction in Medicaid rolls without any significant increase in employment. Recent data reported by Arkansas, the first state to implement the policy, indicate that over 12,000 people lost coverage between September and November 2018, while only 1,500 of those met the work and reporting requirements in the same period. Practical obstacles to meeting the requirement include the unusual stipulation that all documentation by enrollees, many of them poor and with little online access or literacy, be performed online.


Cost is increasingly the subtext of every discussion about health care access. According to an October 10 report from the nonpartisan Economic Policy Institute (EPI;, "U.S. spending on health care is higher than in peer countries, while quality is lower. These high costs cannot be attributed to overuse of health care[horizontal ellipsis]. Prices for pharmaceuticals, physician salaries, and medical procedures are almost uniformly higher in the U.S. than in peer countries-sometimes staggeringly so."


Although costs of many ACA plans decreased by small increments in 2019, these reductions have not begun to offset overall increases, with some premiums doubling or even tripling since 2014. According to late November reports, marketplace health plan enrollments for 2019 were down from previous years. Potential causes included cuts to ACA outreach and an enrollment period shortened from 90 to 45 days. In addition, according to an analysis from the Kaiser Family Foundation (, "ACA silver-level plans sold in the marketplaces will cost an average of 16% more than they otherwise would have, due to the combined effects of the loss of ACA cost-sharing reduction payments, the repeal of the ACA's individual mandate penalty, and the expansion in the availability of more loosely-regulated plans." The latter, called association and short-term plans, have far fewer patient protections and are likely to siphon younger, healthier consumers away from ACA marketplaces, forcing insurers to charge higher premiums.


Even employer-sponsored insurance (ESI) plans are under intense pressure. According to the EPI report, "The total cost of a family ESI plan rose from $5,791 to $18,142 between 1999 and 2016. As a share of average annual earnings for the bottom 90% of the workforce, these premium costs rose from 25.6% to 51.7% over that same period." The trend has been to pass rising health care costs along to consumers through higher premiums, deductibles, and other forms of cost sharing.


Drug costs are one area where the two political parties may find common ground. The newly elected Democratic majority in the House has vowed to make drug prices a centerpiece in the new legislative session, whether through enabling Medicare and Medicaid to more aggressively negotiate drug pricing or through congressional inquiries into extreme price hikes of individual drugs. President Trump and other Republicans have floated similar solutions.


Other ideas addressing both access and cost being debated by the incoming Democratic majority include everything from a national Medicare for All ("single-payer") plan to replace most current public and private plans to, according to the Kaiser Family Foundation (, "more incremental approaches that would offer a new public plan option alongside existing private coverage and public programs." A comprehensive single-payer plan would require trillions of dollars in funding, but proponents argue that the extra costs would be at least partly offset by getting rid of administrative costs associated with our complex patchwork of insurance options as well as by the far greater power to negotiate health care costs that a centralized health authority would have.


As we've seen to a lesser degree with the ACA, such a transformation of our complex health care system would mean years of transition, especially in the absence of a bipartisan approach. While we've seen that substantive change is possible, it's never fast or easy, and it's always at risk.-Jacob Molyneux, senior editor