In an unprecedented pact among healthcare stakeholders, associations representing physicians, hospitals, insurance companies, and employers have agreed to pursue universal coverage through market-based solutions that build on the reforms in the Affordable Care Act (ACA).
Although the proposal of the Affordable Coverage Coalition doesn’t mention Medicare for All, its approach, if adopted, could have the effect of slowing the movement toward the kind of single-payer system that Senators Bernie Sanders (I-VT) and Elizabeth Warren (D-MA) endorsed when they ran for president last year.
Ironically, however, all of the money required to implement the free-market proposal would have to come from the federal government.
In a statement about the universal coverage initiative, Susan R. Bailey, MD, president of the American Medical Association (AMA), commented, “This new partnership is notable for several reasons, but perhaps the most important is the fact it represents a consensus by all the major players in healthcare about the best way ahead.”
Among the associations in the coalition, besides the AMA, are America’s Health Insurance Plans, the American Academy of Family Physicians, the American Benefits Council, the American Hospital Association, the Federation of American Hospitals, and the US Chamber of Commerce.
Setting Aside Differences
“While we sometimes disagree on important issues in healthcare, we are in total agreement that Americans deserve a stable healthcare market that provides access to high-quality care and affordable coverage for all,” the coalition said in its statement. “Achieving universal coverage is particularly critical as we strive to contain the COVID-19 pandemic and work to address long-standing inequities in health care access and disparities in health outcomes.”
The coalition noted that over the past year, the COVID-19 pandemic has highlighted the link between insurance coverage and better healthcare access and outcomes. “Gaps in coverage limit our ability to connect people to critical public health information and ensure they know how to access the healthcare system, leaving a community vulnerable to the continued spread of communicable diseases,” the group stated.
Largely because of the ACA, the coalition said, “the nation has made substantial progress in expanding access to health coverage.” However, nearly 29 million nonelderly individuals remain uninsured, it added.
Many of these people are eligible for, but are not enrolled in, coverage through government-subsidized plans on the ACA insurance exchanges, Medicaid, the Children’s Health Insurance Program (CHIP), or their employers. Therefore, any plan to establish universal coverage, the coalition said, must include robust outreach and education efforts.
Desired Government Policies
Specifically, the coalition supports the following government actions:
Increase the amount and expand the eligibility of ACA premium tax credits and cost-sharing reductions. Provide subsidies to people with higher incomes and younger enrollees.
Establish a federal funding mechanism to support any unexpected high costs for caring for those with serious health conditions or to otherwise lower premiums or cost-sharing for exchange enrollees.
Automatically enroll and renew individuals eligible for Medicaid and premium-free exchange plans and facilitate enrollment for any remaining uninsured people, maximizing their financial assistance and simplifying enrollment and maintenance of coverage.
Have Congress appropriate adequate funding for navigator, outreach, and enrollment programs, and encourage states to do the same.
Ensure that everyone with an income up to 138% of the federal poverty level has comprehensive coverage. To provide incentives for states that haven’t yet expanded Medicaid to act, Congress should again fund a 3-year, 100% federal match for Medicaid expansion.
To help people who are at risk of losing coverage because of losing their jobs, “Congress should temporarily cover the cost of continuing health coverage through the [COVID-19] crisis, such as through COBRA subsidies or direct loans to employers.” Those who have already lost coverage should be automatically enrolled in Medicaid, CHIP, or ACA marketplace plans.
The coalition said that because minority and LGBTQ populations are less likely to have health insurance than White and heterosexual people, “addressing unequal access to insurance is an important starting point” in achieving health equity. However, the coalition added, inequity is likely to be exacerbated because employer coverage has become less available during the pandemic, and state Medicaid programs are struggling to cope with the increased demand for coverage.
The document does not address the challenge of covering undocumented immigrants, although they represent a substantial portion of the uninsured, according to the Kaiser Family Foundation. In the only mention of this population, the coalition said, “Recent regulations have discouraged families with undocumented family members from enrolling for fear of immigration consequences, resulting in a decline in insured children for the first time in two decades.”
Biden Administration Alignment
The Biden administration is aligned with some elements of the coalition’s proposal. For example, the proposed American Rescue Act would increase ACA insurance subsidies and remove the subsidy “cliff” that leaves out people who make over 400% of the federal poverty level. The US Department of Health and Human Services has restored federal funding for ACA outreach and education in connection with a new enrollment period on the insurance exchanges. In an executive order, Biden said he plans to strengthen Medicaid, although he hasn’t yet called for giving states that haven’t expanded their Medicaid programs federal incentives to do so.
The proposal to create a federal funding mechanism to cover unexpected high healthcare costs resembles an existing federal waiver program that, among other things, allows states to create reinsurance programs for ACA exchange plans. As of last November, 16 states had received such waivers, and most of them were using federal funds to help buy reinsurance to reduce premiums and cost sharing in exchange plans. It’s unclear whether Congress would consider adopting a national reinsurance program, which would probably be very expensive.
The idea of automatically enrolling and renewing individuals in Medicaid and subsidized ACA plans reflects the difficulty of reaching many people who are eligible for these programs. Again, it’s unclear whether Congress would go this far.
A dozen states have yet to expand their Medicaid eligibility to those who earn less than 138% of the federal poverty level. Offering to pay 100% of the additional costs for 3 years might or might not induce them to implement this ACA policy; the federal government currently covers 90% of costs for the states that have expanded their coverage, yet these other states have failed to act.
The coalition did not append an analysis showing how their proposal would achieve universal coverage.