My letter to the Senate Finance Committee about ACA repeal legislation

Note: Given the time constraint--today is the deadline for submitting a letter--I've stolen some of the following from Andrew Sprung:

Topher Spiro of the Center for American Progress acquired a letter from Senate Finance Committee Chair Orrin Hatch to healthcare "stakeholders," inviting their input by May 23 on Republican senators' efforts to write an ACA repeal bill. Hatch asked that letters be sent to

Since the Republican senators' bill-writing process is as secretive and rushed as the House's, Spiro seized the opportunity to encourage non-privileged "stakeholders" -- all of us -- to send their two cents to the email address provided. He has offered to tweet any letters tweeted at him, with a screenshot.

Here's mine:

Dear Members of the Senate Finance Committee:

I run a website called which some of you may be familiar with; for 3 1/2 years I’ve devoted countless hours to tracking and analyzing the impact (both positive and negative) of the Affordable Care Act on healthcare coverage and premium rate hikes nationally.

My work has been cited and utilized by both Democratic and Republican lawmakers and by both progressive and conservative media outlets as being reliable, accurate and comprehensive. It’s no secret that I generally support the ACA overall as an improvement over the previous state of healthcare in the U.S…but I’ve also never shied away from reporting on the considerable flaws and bugs in the law either.

I happen to be self-employed, as is my wife, meaning that we (along with our 11-year old special needs son) receive our own coverage via an ACA exchange policy here in Michigan. In fact, we were among those who received a cancellation notice back in October 2013 stating that our Blue Cross Blue Shield of Michigan policy was being discontinued due to not being ACA compliant.

It’s also worth noting that our family income, which varies widely from year to year, happens to fall within the 300-500% FPL range…which means that depending on the year, we receive either no APTC assistance whatsoever or only a nominal amount, while our own rates have indeed increased substantially over the past several years.

With this in mind, here’s what I would like to see happen in order to improve the healthcare system in America in the short term:

FIRST, what you shouldn’t do:

  • Don’t eliminate or weaken the ACA’s Medicaid expansion provision.
  • Don’t weaken or cut Medicaid in general via block grants or per capita caps on federal funding.
  • Don’t eliminate APTC or CSR financial assistance, which are based on income, rating area and benchmark policy rates.
  • Don’t weaken or compromise on ACA protections which prohibit medical underwriting while requiring guaranteed issue, community rating and essential health benefits.
  • Don’t try to pass the buck on the above issue by allowing individual states to get waivers allowing them to weaken or eliminate those protections.
  • Don’t eliminate the funding mechanisms for APTC, CSR and Medicaid expansion.

As for what I think you should do, I’ve written up a list of 20 repairs/improvements which I believe would improve the ACA specifically, and American healthcare coverage in general.

Here’s the summary version:

  1. Lock in CSR reimbursement payments legislatively.
  2. Restore Risk Corridor Funding.
  3. Fix the “Family Glitch”.
  4. Fix the “Skinny Plan” Glitch.
  5. Encourage the 19 non expansion states to expand Medicaid.
  6. Encourage more states to launch the Basic Health Program.
  7. Restructure and enhance the APTC provision.
  8. Enhance CSR eligibility and cut the Silver plan exclusivity on it.
  9. Increase the Individual Mandate Penalty.
  10. Require that all Individual Market policies be sold on-exchange exclusively.
  11. Allow undocumented immigrants to enroll in exchange plans (at full price).
  12. Tie participation in Medicare Advantage contracts to individual market exchange participation.
  13. Establish a reinsurance program either nationally or on a state-by-state basis.
  14. Institute an 80/20 MLR requirement for pharmaceuticals similar to the MLR requirement for insurers.
  15. Let Medicare negotiate drug prices.
  16. Fix the “Silver Spam” plan gaming problem & make standardized plans mandatory.
  17. Merge rating areas statewide.
  18. Merge the individual and small group risk pools statewide.
  19. Establish a Public Option provision…at least for counties without any carriers participating in the individual market.
  20. Allow Medicare buy-in from age 55 and up.

For the Republicans among you: I’m aware that most of the above are likely “too progressive” for your taste, and that additional funding would be required for many, which you are no doubt loathe to agree to. However, there are several of them (highlighted above) which would cost nothing, such as numbers #10, 11, 12, 14, 15, 16, 17 & 18.

As a stakeholder in the U.S. healthcare system, I expect this letter to become part of the public record in your deliberations. Thank you for reading.


Charles Gaba