Access or Coverage? The Election is Driving Team Changes

When President Trump enhanced the flexibility of Section 1332 with 2018 regulatory guidance that promoted State Relief and Empowerment Waivers, his detractors were critical that it allowed the Affordable Care Act’s (ACA) ideals to be violated. Never mind that we had already lapsed concern that the ACA live up to those ideals, but instead were committed to assuring the general public of its allegiance to a popular catchphrase, while insisting that any replacement legislation would unequivocally fall short.

A primary complaint with the updated 1332 guidance was that it only required “access to coverage”, not actual coverage itself. In a Health Affairs blog, Katie Keith said, “In a significant shift, the Departments will no longer look to the actual coverage purchased under the waiver to ensure that coverage is available to a comparable number of residents. Instead, waivers will be evaluated based on whether residents have access to comprehensive and affordable coverage under the waiver, even if they do not enroll in this coverage.” After all, what usefulness does “access” provide if it does not result in attractive coverage that people will buy? It was a fair question to be asked, but one that was short-lived.

Fast-forward two years and the ‘access vs. coverage’ competition discussion has risen again. Actually, it has not and that is why I am raising it now. The ACA failed miserably in meeting its stated intended goals. It was supposed to lower costs. It was supposed to result in a vibrant individual health insurance market two to three times the size of what we see today. The troubled marketplaces paved the way for the 2016 election of an unlikely president, who surprisingly (to many of us, not all) strengthened the law and made it more popular rather than repealing it.

While the market strengthening has been kept under the radar (perhaps only for four more weeks) and large, populous states have been slow to leverage new opportunities, many ACA supporters have begun promoting something more opaque than its emerging success. We’ll get to that, but let’s examine actual coverage levels first.

Brian Blase developed the graph below and reports that the individual market has grown by a mere 2 million people due to the ACA. With $50+ million in annual spending, “the federal government is spending a staggering $25,000 for each new individual market enrollee.” When the group market is included to account for potential migration, overall private market insurance coverage has strikingly declined since 2009.

With the exception of enhanced federal funding which encouraged states to expand Medicaid eligibility, the ACA has not expanded coverage. So how do we champion the ACA's purported success now? There are two ways. The first is to highlight the ACA makeover and insist on legislative patience, but that is not politically palatable to those who require that the new US president be the boogeyman in this discussion.  The second is to look at the title of this article and decide the only hope is to change teams. That’s right. Those who criticized the change in Section 1332 requirements from a 'coverage to access' guardrail test are now blatantly promoting the ACA with an 'access over coverage' sentiment. Here’s the far-fetched play: While the ACA is a coverage disappointment, presumably there are hundreds of millions of people who have group insurance today at risk of losing their employment, losing insurance coverage, and being unable to "access" other insurance. It's a false fear of an imagined pre-ACA environment without federal funding and new difficulty finding reasonably priced insurance, one that we know is not a realistic outcome and one that we also now know actually resulted in more people being insured.

It's a tough argument, but there really are no blue pill alternatives. The ACA has resulted in fewer people having private insurance coverage, and many that do have coverage pay higher prices for leaner coverage and skinnier networks, but supposedly the original law was a success because people may have more “access” in the future. I'm not buying it. Perhaps Congress remedying the constitutional concern and new legal dynamics educating stakeholders will lead to state actions resulting in both better access and more coverage. Let’s hope that many of the people who have recently flipped to the access team would welcome that news; maybe they will be willing to have a transparent discussion about improving individual health insurance markets and rejoin the coverage team beginning November 4th.