WashU Expert: Obamacare to get a rebuild

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Karen Joynt Maddox, MD, is an expert and researcher in hospital and health-system efficiency, among many other aspects of modern-day health care. As co-director of the Center for Health Economics and Policy, an assistant professor in the cardiovascular division of the School of Medicine and a cardiologist, she has both worked under and scrutinized the Affordable Care Act also known as Obamacare — launched while President Joe Biden was vice president.

Joynt Maddox expects the new Biden/Kamala Harris administration to retool and reinforce Obamacare, rather than the previous administration’s failed attempts to repeal and replace. She offers areas ripe for both quick and gradual change: reinstating health discrimination protection, investing in insurance enrollment, creating the “public option,” and broadening competition in insurance markets.

Joynt Maddox

“When any new administration takes charge, there are things that they can do quickly and unilaterally — think executive orders and regulations — and things that require time, coalition-building, and compromise — think legislation. Some changes are likely to come quickly; others may take many months to years,” she said.

“In the quick bucket, the Biden/Harris administration has signaled a number of places they intend to act. Anticipate executive orders reinstating health discrimination protection for transgender people, reversing new Trump administration restrictions on reproductive rights, and reinvesting in Obamacare enrollment outreach and assistance. In the coming months, there will likely be regulatory changes reversing recent regulations that weakened protections against so-called ‘junk insurance.’ Within the Medicaid program, which was responsible for about three-quarters of the 20-million-person coverage gain under the Affordable Care Act, Trump-era regulations will almost certainly be reversed that allowed waiver applications for work requirements, block grants and other strategies aimed at reducing rather than broadening enrollment.

“Into the longer-term bucket fall many of the larger, more ambitious priorities. With the outcome of the Senate race in Georgia now determined, the Biden/Harris team has a clearer path to moving some of their proposals to strengthen — and improve upon — Obamacare. While the Affordable Care Act was an enormously important piece of legislation, it was not a perfect one. In more typical times, a bill as large as that one would have undergone a number of bipartisan fixes already — things like shoring up issues with insurance rating areas, streamlining Medicare payment policies and so forth. In part due to the contentious way in which it was passed in the first place, many Republican policymakers, including [Sen.] Mitch McConnell, essentially refused to participate in any fixes short of repeal.

“Now that repeal is realistically dead, I hope legislators can have conversations across the aisle on how we could pass legislation to improve access, quality and outcomes of health care in this country. And they will need to — Democrats’ thin majority in the House and parity in the Senate mean that any attempts at major legislation will need to include moderates and Republicans in order to pass. This effectively takes things like Medicare for All off the table, at least in the near term.

Biden previously announced he would “build upon” the ACA once in office, giving Americans the “choice to get a Medicare-like plan.”

Joynt Maddox said: “Biden’s signature plans during the campaign were to lower the age of Medicare eligibility and create a ‘public option.’ The public option would be a government-run plan, much like Medicare, that people could opt into even if they didn’t automatically qualify for Medicare by merit of age, disability, or having one of a few specific conditions. This would be particularly attractive among self-employed individuals or those who lack coverage through an employer, particularly those who live in areas without an affordable plan on the individual market. However, depending on how such an option were designed, it could compete with employer-sponsored insurance as well. Because of its sheer size, Medicare can pay less to clinicians and hospitals and still remain ‘in-network,’ which could both mean affordability for consumers and an infusion of price competition into the remaining private market. There will surely be major political battles about the details of such a program, but look for it to emerge as a major issue for the administration.

“Less flashy but also important legislative proposals to shore up the ACA that could find bipartisan support in the Senate include lowering the cap for the proportion of personal income that can be spent on insurance before subsidies kick in (from roughly 10% to roughly 8.5%), changing the benchmarks against which insurance subsidies are set, and changes to encourage competition in insurance markets. There almost certainly will be action on prescription drug pricing and improving generic drug supply. It is also likely that the Biden/Harris team will look for ways to make Medicaid expansion more attractive for the remaining states that have declined to expand thus far, as well as more efficient among those that have expanded.

“Anticipate a flurry of executive and regulatory activity in the first few months of the new administration; for major change, legislation, compromise — and longer timelines — will be needed.”

Read more from WashU experts regarding an array of policies and initiatives ahead in the new administration’s first 100 Days.

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