The issue of how to improve health care in the United States is complicated. At a RAND event, senior economist and Paul O'Neill Alcoa Chair in Policy Analysis Christine Eibner discussed modifications to the Affordable Care Act and the long-term outlook for health care reform.
Americans expect affordable coverage for pre-existing conditions, access to routine services, and protection from unpredictable and significant financial risk from accidents or illness. As a product designed primarily for risk protection, insurance may not be the most efficient or affordable approach to achieving all of these objectives.
Paying for health care coverage is a challenge for Americans facing rising premiums, deductibles, and copayments. The ACA's tax credits that make marketplace insurance more affordable for lower-income individuals should be extended to middle-income adults aged 50–64.
Despite their differences, the Affordable Care Act and the current proposals to replace it take a similar approach to providing health insurance. What might some alternatives look like? And how could they provide coverage to more Americans?
As Congress considers repealing and replacing the Affordable Care Act, it will need to consider how federal budget scoring can affect the fate of legislation. Depending on the ultimate cost of a replacement, finding enough savings to offset costs while maintaining budget neutrality could make it hard to pass a replacement.
The impact of RAND's Health Insurance Experiment has been wide-reaching. The study's conclusions encouraged the restructuring of private insurance and helped increase the stature of managed care in the United States.
The ACA encourages workers to retain employer coverage by restricting their eligibility for marketplace subsidies. Modifying the policy could help 700,000 people gain coverage and lower spending for 1.6 million who are insured but face high health care costs under current ACA policy.
As policymakers consider alternatives to reduce the federal government's financial burden from providing subsidies under the ACA, they should consider the consequences for enrollees. Existing premium-support models yield considerable savings for the federal government but could create age and income disparities in coverage.
Since September 2013, the number of people with health insurance coverage has increased by 16.6 million. But since the second ACA open enrollment period in February 2015, the number of people with coverage has remained relatively flat. The third open enrollment period began on November 1. Whether the number of uninsured will continue to decline remains an open question.
Under the Affordable Care Act, older adults cannot be charged more than three times as much as 21- to 24-year-olds for the same plan. Changing this rule to 5-to-1 may not be a cost-effective way to encourage enrollment among the young and healthy.
As part of its goal of near-universal coverage, the Affordable Care Act requires most Americans to obtain insurance or pay a penalty. Repealing that requirement would significantly reduce health insurance enrollment and cause individual market premiums to rise.
The Affordable Care Act has officially been part of the U.S. health care landscape for five years. We reflect on the twists and turns that followed its passage and the RAND research that informed debates along the way, and look ahead to the future of the ACA.