The Current Threats to the ACA: The Insidious, the Callous, and the Flat-Out Cruel

Well then. It’s been quite a couple of weeks, and it’s now time to take stock of where we are in the fight to protect the Affordable Care Act. By working together to put pressure on our elected officials, we successfully halted the first incarnation of Trumpcare, also known as the American Health Care Act. Give yourselves a round of applause!

Refreshing our memories on that delightful (I say with all the snark that ever was, is, and will be) bill and the process by which Republicans intended to pass it is imperative, because lo and behold, it has risen from the dead. Trumpcare 2.0, or what some folks on Twitter have taken to calling Zombie Trumpcare, restores all of the horrendous provisions in its predecessor but manages to be even worse. It’s hard to believe that that’s possible, but never put it past GOP hard-right ideologues to surprise us with something new and awful.

What’s so atrocious about Trumpcare 2.0? In wonky terms, it eliminates the federal requirement that all insurance plans cover essential health benefits (EHBs) and ends the ACA’s reform that required insurers to stop the practice of individual rating and switch to community rating. It also returns us to the days of yore with Republicans’ addition of grossly underfunded high-risk pools for the chronically ill. Is this what making America great again looks like? I don’t think that word means what Trump thinks it means.

Let’s get into what those terms of art mean in plain English and how they impact all of us. Quite literally, tampering with the ACA will leave no one unscathed. Starting with essential health benefits, they’re so dubbed for a reason. What is that reason, you ask? At the risk of falling into a tautology, they’re, well, essential, and encompass the entire medical field. Without EHBs, your insurance plan doesn’t have to cover outpatient care, hospitalization, emergency care, maternity care, pediatric care, mental health care, preventive care, chronic disease maintenance care, prescription drugs, laboratory services, and then some. So yes, that’s insurance without insurance. Nominally you might have an insurance plan, but in practice it’s a worthless piece of paper. Trumpcare 2.0 permits states to opt out of EHBs, so whether your plan covers these basics would be entirely down to the luck of the draw dependent on where you live. And guess what? That means people whose plans don’t cover EHBs will have more recourse to hospitals, which means that excess hospital spending will fall on taxpayers. Ultimately, then, consumers aren’t saving money, since funding to cover community healthcare needs has to come from somewhere. What ending the EHB requirement means in practice is that in some states, insurance will become meaningless. That’s neither just nor humane.

And then there’s the end of community rating. Prior to the ACA, insurance companies determined their prices via individual rating, meaning that they would decide how much to charge you based upon your health status, ability, age, sex, gender, and other personal factors. For instance, if you were a young person with a chronic disease, insurers could and often did refuse to cover you, because of the cost of your medical care to stay alive and functioning and how it would mount over time. If you were a woman, you could and often were charged more because you might become pregnant or have female-specific health issues (a particular mode of sex discrimination in healthcare that has a long and fascinating history). If I were to continue listing examples, we’d be here all day, so I’ll stop here for now. The ACA instituted community rating, meaning that insurers have to charge the same price to all residents within given age brackets living in a demarcated geographic area. The only other factor that can alter prices for individual consumers is tobacco use. That meant the end of insurers requiring you to provide intimate medical details, the end of people with preexisting conditions being denied insurance precisely because they desperately needed it, and the end of women paying significantly more for healthcare than men. Ending community rating will take us back to those happily bygone days, with the exception being that insurers cannot flatly deny to cover people with preexisting conditions. Instead, they can charge these folks absurdly high premiums, which effectively amounts to the same outcome. Once again, people with preexisting conditions would have to choose between managing their diseases and disabilities or avoiding bankruptcy. It’s unconscionable, quite literally adding insult to injury, punishing sick people because they have the misfortune to be sick.

On to high-risk pools. Having fun yet? Spoiler alert: we’ve tried them before and they don’t work. Basically, the idea is to shunt everyone with a significant medical condition into one group, or pool. But it doesn’t take a mathematical genius to understand that if you put everyone with the highest medical costs together, the result will be even higher collective medical costs. High-risk pools are also no guarantee that the people in them will receive quality health insurance. In fact, the opposite is likely to be true, since quality health insurance would be even more expensive. Sure, segregating people with preexisting conditions could lower premiums for healthy people, but at a dreadful cost (both literally and figuratively) to sick people. That’s discrimination, plain and simple. And the GOP is only added peanuts, just $15 billion over nine years, for the high-risk pool. Given that Humira, a biologic used to treat various autoimmune diseases, costs over $7000 without insurance for a starter pack and refills ring in at over $2000…clearly, $15 billion is laughable. For a reality check, all of this assumes that people could actually get into the high-risk pool, which isn’t a given. In prior history, high-risk pools became so expensive that sometimes people faced a waiting list to get in: an additional injustice to chronically ill people, because serious disease waits for no one.

Trumpcare 2.0 is a direct assault on people with preexisting conditions and women. Ending EHBs and community rating together represent a major blow to those living with chronic illnesses and disabilities, and renders the so-called guarantee that all people, regardless of health status, can get coverage useless. If coverage is unaffordable, it is not accessible. If coverage doesn’t cover much of anything, it’s worthless.

So that’s where we are legislatively. We must hold our representatives accountable and demand that they stand up and fight for the health and lives of their constituents. People are not political pawns, and our representatives need to hear that from us. If your representatives are firm supporters of the ACA, that’s wonderful! Still reach out to them to thank them for their stance and urge them to hold strong. Tell them you have their backs. And if you don’t want to call or can’t get through, text “resist” to 50409, which will permit you to fax your representatives for free via text messaging. Which I think is super cool.

If you recollect, however, legislation is but one prong of the assault on the ACA. Remember, Trump and Price can harm the ACA all by themselves. The White House spoke of a three-pronged strategy, and we’ve still got two prongs that are rising in importance and that must remain on our radar. Let’s focus specifically on prong number two, which can wreak massive damage on the ACA with far less fanfare than major legislation. Trump and Price have significant power over the ACA, and they can alter the law and its enforcement through regulation — which Price has already announced that they plan to do. The list of ways in which they can decimate the ACA is beyond disturbing, and I’ll go through a couple of the most concerning ones here. Ending EHBs as described above is also an action that Price and Trump can take themselves, so we have to watch both the White House and Congressional Republicans on this one.

Among Trump’s first actions in office, he issued an executive order that significantly weakened the individual mandate of the ACA. The individual mandate is the linchpin of the healthcare reform law. By requiring all people to get covered or pay a penalty tax, it spreads cost around so that insurers can cover folks with preexisting conditions and children up to age 26. It’s what makes the “affordable” part of the Affordable Care Act happen. If you continue to require that insurers provide coverage to people with preexisting conditions but don’t require that all people pay in in some way, then you’ve got a financially unsustainable system. Healthy people will leave the market, and costs will spike exponentially as only sick people who depend upon insurance remain. Meanwhile, emergency room costs will go up, as people will return to the ER to seek treatment that they otherwise won’t be able to access. Stopping enforcing the individual mandate is good for no one, and yet it’s entirely plausible that Trump and Price may decide to do so. Relatedly, Trump could stop enforcing the employer mandate, so that your job no longer needs to provide you with insurance.

Trump could also decide to stop fighting the House v. Price lawsuit (formerly House v. Burwell). Under the ACA, insurers have to charge low-income people lower rates, so that they can afford healthcare. In return, the government reimburses them with what’s called cost-sharing reductions (CSRs). If the government ceases to pursue this lawsuit, CSRs end, so insurers will have less of an incentive to enter the marketplace since if low-income people sign up, they’ll lose money. Republicans asserted that they would continue approving CSRs through the end of 2017, but there’s no word on 2018 yet. Trump is currently threatening to hold CSRs hostage to force Democrats to bargain away the ACA. This will injure and kill people, all for the sake of perceived political points that will grandiosely backfire against Trump, since he will be to blame if he kills the ACA. As the deadline for insurers to decide whether they’ll offer plans on the individual market — June 21st, though it’s even sooner in other states — is fast approaching, the government is running out of time to declare its intentions on the suit. Insurers need this information so they can determine whether they’ll offer plans on the exchanges. Given that Anthem, a long-time ACA participant, has already signaled that it will pull out of the marketplaces for next year, and Wellmark said that it would not offer coverage in Iowa, we’re reaching a crisis point. Insurers need to know what’s happening now. Some counties and states could be left with only one insurance option or even none at all. Call me crazy, but I don’t think that an insurance system without insurance is all that valuable.

The very existence of ongoing talks about the future of the ACA and various versions of Trumpcare is itself enough to undermine the ACA. It impels insurers to think twice before agreeing to offer plans to consumers. As long as Trump continues to stir up doubt in the stability and longevity of the ACA and marketplaces, it’s hardly a shock that insurers are hesitant to provide coverage. Add to that the uncertainty about whether the government will continue paying CSRs, their already evident reluctance to encourage and remind people to sign up for health insurance, and Republicans’ persistent insistence that the ACA is falling apart (it’s not), and it’s easy to see why insurers have every reason to be wary. Trump needs to soothe insurers’ concerns and recognize that if the ACA fails, he will own it in the eyes of the American people.

Meanwhile, Trump issued new rules that are intended to stabilize the insurance market. To be clear, they stabilize the insurance market in exactly the same way that jumping off a bridge promotes your longevity. They halve the enrollment period to only six weeks, put major obstacles in the way of people obtaining healthcare, and force people to pay more for skimpier care. If you lose health insurance because you can’t afford it but then want to sign up again, guess what? You might need to pay all those back payments you missed because you couldn’t afford them. That could easily amount to hundreds or thousands of dollars. It flouts guaranteed issue, which requires health insurance companies to cover everyone who applies. Given that now the deadline to sign up falls right around the holidays, it’s that much less likely that people will be able to scrape together the money they need for healthcare — unless, of course, we scrap all other presents and get each other the gift of healthcare coverage instead. Somehow, I don’t think that’ll go over all that well with the kids.

Now, let’s say you’ve managed to cobble together the money you need for a special enrollment period. You’re still not out of the woods, because now you’ll have to undergo preapproval verification and prove that you should get coverage. Imagine you’ve jumped through all of these hoops and you’ve finally obtained your health insurance. Don’t get too excited, because now you’ll be paying more money for less care. For instance, you could pay for a plan that once covered approximately 70% of your medical costs, but now it only covers in the mid-60% range. That means deductibles and CSRs will increase, particularly problematic given that the Trump administration is currently threatening to hold CSR payments hostage. Long story short, you’ll see a dramatic spike in your healthcare costs, in the neighborhood of $1000 or more.

These rules together will cause the number of young and healthy people in the marketplace to decline. Young and healthy people tend to sign up at the last minute, so curtailing the enrollment period will result in fewer young people entering the insurance pool. Young people also often don’t have lots of money, so they will be unable to afford the higher expenses these rules will cause. And adding lots of red tape would make anyone leery of signing up, because anyone who’s ever been on hold on the phone and transferred from department to department knows how headache-inducing that is. With fewer young and healthy people in the marketplace, prices will spike, which will hurt all of us.

Which brings us to the question of what we can do. Of course, it’s essential that we keep calling our federal representatives to urge them to protect the ACA. Remind them of the number of people in their districts who suffer from preexisting conditions. Hold them accountable and demand that they protect the lives and health of the American people. Individuals with chronic illnesses aren’t walking pricetags, but human beings who deserve to live as healthy, full, meaningful lives as possible. Make sure that your representatives know that, and that you will make your position felt at the ballot box if they throw folks already dealing with unimaginably difficult medical situations under the bus. And keep pointing out that not only is the ACA doing well, it’s on track to do even better next year if Republicans and Trump don’t decimate it. And of course, support your Democratic representatives, who are fighting against all of this tooth and nail. Watch lawyers who are researching the possibility of challenging Trump in court.

While you’re at it, remind them that the Hyde Amendment in fact exists, and that it prevents federal funds from covering abortion. Repeat, no taxpayer dollars fund abortion. Paul Ryan particularly needs to learn this, given that he seems to think that Trump’s quietly signing away Title X funds from women’s health clinic stops federal funds from paying for abortion, rather than what it actually does: stop women from accessing preventive care, cancer screenings, and basic medical care.

It’s also time to begin calling your state representatives. If the federal government won’t step up to enforce the individual and employer mandates, to keep paying cost-sharing reductions, and to run advertising campaigns to urge people to sign up for healthcare, states can. We’re down to the wire, though, so states would have to act swiftly for this to be effective. We can also push the 18 states that have yet to expand Medicaid to do so, which will cover millions more people while making it that much harder for Republicans to dismantle Medicaid as many want to do. Although the recent effort in Kansas just barely failed, the narrow margin of defeat shows that we can win this if we keep at it. There’s no good reason not to expand Medicaid and lots of good reasons to do so. Find out the status of Medicaid in your state and while you’re on the phone with your representatives to urge them to protect the ACA, also urge them to expand Medicaid with the resources that the ACA provides.

Yes, the fight to save and protect the ACA is decidedly trickier now, since we’re not predominantly dealing with a monumental piece of legislation. We won a victory, but we’re by no means out of the woods. Here’s your invitation to Prong Number Two, though be sure not to take your eyes off Prong Number One. There are plenty of actions we can encourage our representatives to take and to push, both on the state and federal level. Stay vigilant. Stay vocal. Stay active. And really, give yourselves a round of applause for halting Trumpcare: The First Edition. We’ve leveled up to round two, and we’ve proven that we’re ready for the challenge if we stick together.