Vice President for Health Policy
Senator Lamar Alexander, Chairman of the Health, Education, Labor, & Pensions Committee, said this week what more congressional Republicans are starting to acknowledge: policymakers shouldn’t repeal the Affordable Care Act (ACA) without first enacting “concrete, practical reforms” to replace it. But his plan lacks critical details needed to compare it to the ACA in coverage, affordability, and the adequacy of coverage it would provide. In particular, his plan fails to reflect an actual ACA replacement in these ways:
Nor did he say whether insurers could once again charge higher premiums based on gender and occupation and hike premiums for older people. These are crucial questions. As we’ve explained, it’s hard to see how eliminating the ACA’s individual mandate wouldn’t destabilize the individual market if existing protections for people with pre-existing conditions were fully retained. Many healthier people would likely go without health insurance, which would leave mostly sicker people in the risk pool. That would drive up premiums and cause insurers to withdraw from the market.
For example, he proposed “eventually” creating a new tax credit to replace the marketplace subsidies but didn’t explain who would qualify, how much it would be worth, and whether it would be sufficient to limit premiums to a share of income, as the ACA does. Likewise, he called for expanding state Medicaid flexibility through waivers but didn’t say what kind of flexibility or what consumer protections (such as requirements that states cover certain groups and benefits) it might allow states to drop. Nor did he say whether his plan would maintain the ACA’s Medicaid expansion and how it would ensure that children, seniors, people with disabilities, and low-income families could continue receiving affordable Medicaid coverage.
Also, his proposal to expand Health Savings Accounts, which is at the center of many Republican health plans, would do little or nothing to help low- and moderate-income people get coverage. High-income people — who likely already have health coverage — would be the biggest beneficiaries.