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The Exchange

Repeal and Replace? Not So Fast, Say Some Republicans

Herry Lanford via Flickr/CC

Repeal, Replace, Repair, Retain. Now that they’re in a position to dismantle Obamacare, some in the GOP appear to be urging restraint. Even President Trump, who joined the Repeal and Replace rallying cry during his campaign, has recently sounded more hesitant, suggesting that a new plan may be in place next year.

Republicans in Congress have meanwhile been contemplating their next steps, said Dan Gorenstein, senior reporter for Marketplace's Health Desk, on  The Exchange.

“They're really interested in doing something, and I think now that they have the responsibility they're quickly picking up just how difficult this is. A simple repeal and replace immediately is seen as both politically and policy wise perhaps a little foolhardy. And so they're tapping the brakes, they’re slowing down and they're trying to really come up with a very serious plan.”

Gorenstein said U.S. House members have been getting into the nitty gritty of the law, teasing out how insurance is defined -- and what people are and aren’t guaranteed under insurance. They’re also softening their language. “What we heard for years was this very heated rhetoric, and I think you’re beginning to see that modify itself,” Gorenstein said. 

Lawmakers’ constituents are also expressing fear and consternation about losing coverage, he said. “Republicans are trying to figure out how to package this, how to manage, this and how to really tackle it.”

James Capretta, resident fellow at the American Enterprise Institute, said Republicans have a chance now to make a major difference.

“So their ambition I think needs to be -- what do we want to do to move health care in a market-oriented direction where it will improve and bring better services to people over time. That's a complicated thing. It's a big deal but I think if they put their ambition and energy into that then they have a chance to do something pretty significant, he said.

Capretta is among those who feel the ACA fell far short of its goals.

“There are about 29 million people according to the Census Bureau who are uninsured in 2015. A large number of people are exempting themselves out of the system largely because they find the products unattractive on the exchanges. Approximately 10 million or so people have exempted themselves from the individual mandate for a number of reasons and another several million people paid the tax instead of buying insurance. Moreover there are a lot of people that are eligible for coverage and haven't enrolled yet.

Lucy Hodder, director of health law and policy programs and a professor of law at UNH Law, sees it differently, particularly when it comes to New Hampshire.

"In 2010,11 percent of our population did not have insurance and now it's down to 6.3%.  We have coverage opportunities at every level. It's comprehensive coverage. I guess the question we still are grappling with is -- how do we make it more affordable? And that really is an everybody-at-the-table conversation.

Medicaid Expansion

Among the major changes under the ACA, according to Gorenstein, was the expansion of Medicaid coverage to include people up to 138% of poverty.

“Previously in most states the only people who could have Medicaid would be people who had children and were very poor and the disabled this open that up you didn't have to have a child anymore you could you could make a little bit of income. This would apply to lots of people in New Hampshire for example who have seasonal work but not consistent year round work. So they've got some money, they're working, but they don't have that full-time kind of job. And so those people now all of a sudden had access to insurance."

Senator Jeb Bradley, a key architect of New Hampshire’s Medicaid expansion plan, said the program covers more than 50,000 Granite Staters who did not previously have access to traditional Medicaid and would not have qualified for ACA subsidies to buy insurance on the exchanges.

“And they have improved health outcomes and I think that's something very very important. Could we with a block grant have greater flexibility from Washington to design a program that is more effective as well as being more cost efficient? I think the the answer is, yes, we could."

Hodder said, however, that block grants allow the federal government to reduce the amount of money it contributes to Medicaid.

“So we have to be extremely careful and negotiate with all of the expertise we can bring to bear if we're going to move into that kind of a system where there's a cut off without any relief. And it takes a lot of discipline to implement a block grant for the best interests of those it's intended to serve which are most needy in the population."

Senator Andy Sanborn, who opposed Medicaid expansion, would also like to see block grants, as well as the return of low-cost high-deductible catastrophic plans. “We have to allow people to come in at whatever level they want and hope they don’t have to utilize it so the pool has the resources to help those that are in need."

Capretta said Medicaid expansion did not fix Medicaid.

“I don't think we should kid ourselves and say we expanded Medicaid and therefore all things are great. There have been scores and scores and scores of studies by the government accountability office and others showing major integrity problems in the Medicaid program and moving away from the matching system is critical to fixing that.”

Capretta also said the ACA leaves out a large group of people:

"If you're below about 250 percent of the federal poverty line then they're providing pretty generous subsidies to enroll in the exchanges. But if you're above that -- you're working, you're a moderate income person and you're making 40 or 50 thousand dollars a year -- and you go to buy your insurance on the exchanges and you're trying to make ends meet,  the premiums are going to be quite high... So for that kind of family they're going to say gee whiz this doesn't seem like that great of a deal for me."

I own a one man LLC. I've owned it for about 17 years and I'm extremely healthy and basically almost never go to the doctor and I have been buying an Anthem Blue Cross plan that was about $5000 deducti**ble and the premiums were going to go up to $550 per month this year. So I decided to take a look at the ACA and I actually have picked up a plan for the same deductible and I get all of my preventative visits covered now for only $450 a month. I'm well outside of the subsidy range. So I'm an example of somebody who's done extremely well by making the switch over. - Jim, Exchange listener

Hodder urges caution in considering any changes to the ACA: 

"I think that what we really have to be careful about is is trying to undo the investment we've made in this solution so that it costs more. Every change costs our system, creates instability, creates confusion, and that's a huge cost to everybody. So I hope it takes time because we just implemented this new experiment and we're starting to see some of the benefits."