Urban Institute jumps onboard the "What's Next after the ACA?" train with "Healthy America"

Mon, 05/14/2018 - 10:59am

It's very clear that the name of the game for healthcare policy this year seems to be "What comes after the ACA?"

For over a year now, I've been strongly urging the passage of some sort of "ACA 2.0" upgrade package, primarily based on my own wish list entitled "If I Ran the Zoo", a collection of about 20 assorted ACA fixes. The reality is that a couple of the items on my list start to move away from an "upgraded ACA" and drift over into what I've mentally compartmentalized as the next phase in achieving Universal Healthcare Coverage.

Since I first posted my wish list just over a year ago, several new proposals have been released by various Democratic politicians and 3rd-party organizations such as the Center for American Progress, some of which are revised versions of other long-proposed systems. These include:

1/2. Bernie Sanders new* "Medicare for All" proposal
(*as opposed to the prior version, which wasn't really a plan at all; similar to John Conyers' long-promoted HB676)
3. Tim Kaine & Michael Bennet's "Medicare X" (very edgy name!)
4. Brian Schatz's "Medicaid buy-in" (I don't know the formal title)
5. The "Undo Sabotage & Expand Affordability Health Insurance Act"
(USEAHIA?? For the love of God, guys, pick a catchier name)
6. The "Consumer Health Insurance Protection Act"
(aka "CHIPA"...a better acronym, but too easily confused with CHIP)
7/8/9. The Center for American Progress's "Medicare Extra" plan
(very similar to Pete Stark's "AmeriCare" and Jon Walker's "MICA")
10/11. Jeff Merkley & Chris Murphy's "Choose Medicare" or "Medicare Part E" act
(largely based on a proposal by Poli Sci Professor Jacob Hacker)

As you might expect, there's some amount of overlap between all of the above, but in my view, they also fall into two fairly distinct groups:

Medicare X, USEAHIA and CHIPA (#3, 5 & 6) are what I would consider "ACA 2.0" bills...they're improvements of the current ACA structure (Medicare X is pretty modest; the other two are quite robust), but none could be considered a terribly disruptive "game-changer". I admit to not having read up too much on Medicare X, but I've done a fairly in-depth analysis of the other two; here's how both of these "ACA 2.0" bills stack up against each other.

All of the other proposals would achieve either universal or near-universal coverage, although the means and timeline varies greatly from plan to plan.

For the past month or two, I've been urging Democrats to take a 2-phased approach: Push for an ACA 2.0 plan in the short term, mainly to buy enough time to phase in a "Medicare Extra" like policy long term.

Today, however, the Urban Institute has also thrown their hat into the ring with their own near-Universal Coverage proposal, which they call "Healthy America":

Since efforts to “repeal and replace” the Affordable Care Act (ACA) have failed, and bipartisan attempts to improve the law have stalled, some policymakers are now looking beyond incremental fixes. In this paper, Urban Institute researchers present a set of policy ideas that would provide universal access to comprehensive coverage but would also allow people to keep their employer-sponsored coverage, would offer a range of insurer options and ensure broad pooling of health care risk, would not have an employer mandate, would provide income-related federal assistance, and would create a more flexible individual incentive to remain insured than that under the ACA.

The proposal builds on components of the Medicare program and the ACA Marketplaces. However, it simplifies the current health insurance system by integrating Medicaid acute care for nonelderly people and the Children’s Health Insurance Program (CHIP)—while preserving access to their benefits—with coverage for people enrolled in private nongroup insurance and people currently uninsured. This large new Medicare-style marketplace, featuring a public plan and private insurer options, would contain costs by fostering competition among many insurers, capping provider payment rates, and addressing prescription drug pricing. This proposal is less ambitious than a single-payer system (i.e., Medicare for All), but it would get close to universal coverage with much lower increases in federal spending and less disruption for people currently enrolled in employer coverage or Medicare.

They estimate that the plan would result in 15.9 million fewer uninsured people and reduce total health care spending by $28.9 billion in its first full year of implementation.