Over the past year, the Affordable Care Act’s marketplaces for individual health insurance purchases have been rocked by a series of bad stories. A lot of insurers have raised premiums, and a lot of insurers have decided to stop participating in the program, which encourages those that remain to raise premiums. The higher premiums mean that for a certain number of more affluent and relatively healthy consumers, it makes financial sense to simply pay the penalty rather than purchase insurance. Removing relatively health consumers from the marketplace, in turn, encourages higher premiums.
The subsidies offered to lower-income people under ACA are scaled both to income and to the local price of health insurance. Which means that for heavily subsidized customers, the higher premiums don’t drive people out of the marketplace. And there are enough young and healthy people who qualify for generous subsidies to ensure a stable long-term risk pool.
The alleged “implosion” of the ACA’s nongroup marketplaces is totally irrelevant to this debate. Republicans are trying to smuggle a massive policy change through the door without really discussing it on the merits, probably because they think most people don’t agree with them about the relative merits of tax cuts versus providing health care to the poor, elderly, and disabled.
An intriguing subplot to the 2017 health reform debate is that while it’s pretty clear Ryan, Health and Human Services Secretary Tom Price, Office of Management and Budget Director Mick Mulvaney, and other key players understand the gap between reality and their rhetoric, it’s not really clear that the president does. Ryan, Price, and Mulvaney, after all, are all long-term, dedicated budget cutters who favor not just Obamacare repeal but also big cuts to Social Security and Medicare.
Trump seems to take a different view of the welfare state. And it’s at least possible that he is one of the marks of the implosion con rather than one of the perpetrators. That Ryan and his allies, in other words, have convinced Trump that the ACA needs drastic overhaul, and thus that it makes sense for the president to expend political capital on this rather than his signature issues of deporting immigrants and bombing the shit out of ISIS.
Were the fact that this isn’t true to be made clear to him, it might change his thinking.
The CBO’s message is, essentially, that if Trump simply sticks with the status quo, the wave of huge premium hikes and insurer dropouts will end. Since his administration will undoubtedly have tinkered with the relevant regulations in the interim, Trump will then be able to claim that he “fixed” Obamacare — arguably even made it Great Again — with those administrative moves.
Of course, the status quo still wouldn’t be perfect in Trump’s eyes — or in anyone else’s — but that’s the way health reform has inevitably gone in American politics. Obama didn’t think Obamacare was perfect, and neither did the vast majority of Democratic Party legislators who voted for it. Over time, Republicans could make various modifications to the law — and even find bipartisan support for some of them. But the notion of “implosion” has given the campaign for a massive rewrite a sense of urgency that, according to the CBO, is basically unwarranted.