On January 11, 2017

Fixing the ACA makes a lot more sense

Dear Editor,

On Jan. 20, Donald J. Trump will be sworn in as the 45th president of the United States. Mr. Trump has said many times that he wants to repeal the Affordable Care Act—the ACA, or Obamacare—on “day one.” Mr. Trump’s pronouncements are notoriously erratic and changeable, but his choice of Tom Price—an inveterate opponent of the ACA—to lead the Department of Health and Human Services suggests that, on this matter, at least, we should take his word.
As a Vermont physician, I know that repealing the ACA would be a disaster for the state. It would send the number of uninsured Vermonters—which has dropped by half since the ACA took effect—skyrocketing. It would return us to the days when getting insurance was difficult or impossible for the approximately 50 percent of Vermonters who have pre-existing medical conditions. It would re-inflict lifetime insurance limits on close to half of our friends and neighbors. And it would do this without regard to politics or party, hurting Trump and Clinton voters alike.
The ACA is not perfect. Because it relies on private insurance companies, it is inefficient, unstable and subject to price shocks. Inefficient because private insurance companies, with average overhead costs of 15-20 percent of their budgets, simply waste a lot of money when compared to single payers such as Medicare, which has overhead costs of about 2 percent.
Unstable because insurance companies, as private entities, can pull out of markets, change coverage, modify networks, etc., in ways that a public entity, dedicated to the health of the population, never could. And subject to price shocks because the failure to share risks across our entire vast nation means that certain populations are more expensive to insure than others.
Despite its imperfections, the ACA has allowed 20 million more Americans (and 26,000 more Vermonters) to obtain health coverage: People with pre-existing conditions, who need insurance most of all. Low-income people facing a daunting and costly retail insurance market. Young people kicked off their parents’ plans.
It is hard to overstate how valuable this is—to a family with a sick child; or to a diabetic who fears eventual amputation of her legs in the absence of active care. For these and many other people, knowing that treatment is available when needed is the difference between perpetual anxiety and, finally, being able to breathe free.
But haven’t the Republicans promised to “replace” the ACA?  Sure, but as of yet they have no actual plan. If you look at what they’re discussing, none of it adds up. For example, Dr. Price is a big fan of “health savings accounts”—but such accounts may fall short if a medical disaster looms.
He also likes bare-bones insurance, where people pay thousands of dollars in deductibles before benefits kick in, and the benefits turn out to be inadequate, if they are ever used. For Medicaid recipients, he prefers “block grants” to the states, which would reduce the amount of money, and coverage, available.
In fact, nothing the Republicans are discussing comes remotely close to doing what the ACA does already: Provide dependable insurance coverage at an affordable price, which will cover any medical problem that comes up, without bankrupting the patient.
Repealing the ACA would be like tearing down a new extension on your home just because you don’t like the paint job—and with no idea what you were going to replace it with, to boot. A better way forward is to fix and build on what we already have.
There is no shortage of possible improvements, on many of which both parties already agree. For example, subsidies and subsidy cut-offs could be raised so that paying for insurance becomes less of a strain for moderate-income Americans. Medicaid expansion, which as been refused by many Republican governors despite functioning well in other Republican states, could be extended to all parts of the country.
Rate schedules could be adjusted so that young people, who often have less money and are healthier, pay somewhat less than older people. The only limit to the possible fixes is our imagination—implementing them would be a lot easier than starting over.
Vermonters need to remember this when we hear the new administration talking about repealing the ACA. And we need to make clear to our representatives that fixing what we already have makes a lot more sense.

Dr. Wesley Clark, Middlebury

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