30 Issues: Repealing (Or Expanding) Obamacare

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Brian Lehrer: Brian Lehrer on WNYC. Now, it's time for another installment of our signature election series, 30 Issues in 30 Days, where we explore one policy issue a day until the election and look at the Biden versus Trump's stance on that issue. Today, we're up to issue 23 as we begin a stretch of eight days in a row on pandemic-related issues. Today, we'll ask, what if the Supreme Court actually does throw out Obamacare in the case coming next month and of other COVID health insurance questions?

Now, in just a few weeks, the Supreme Court will be hearing oral arguments on whether or not the Affordable Care Act is constitutional. It's not the first time Obamacare has come before the Supreme Court, but it will be the first time with as many as three Trump-appointed justices on the bench. That's assuming Amy Coney Barrett is confirmed. The prospect of a full repeal brings with it a fate difficult to imagine.

More than 20 million people would lose their health coverage and more than 135 million people would lose protections for their preexisting conditions, including, of course, millions of COVID-19 survivors who may still have effects from the illness. What would happen next? What would happen right away before any new system was in place? At the last presidential debate, former Vice President Joe Biden said if the court rules to repeal Obamacare and protections of preexisting conditions would go with that, more tragedy would ensue.

Joe Biden: The deal is that it's going to wipe out preexisting conditions. By the way, the 200,000 people that have died on his watch, how many of those have survived? Well, there's seven million people that contracted COVID. What does it mean for them going forward if you strike down the Affordable Care Act?

President Donald Trump: You've had 308,000 military people dying because you couldn't provide them proper health care in the military. Don't tell me about this.

Joe: I'm happy to talk about this.

President Trump: If you were here, it wouldn't be 200. It would be two million people because you were very late in the draw.

Brian: That was that. At the town hall last week, host Savannah Guthrie asked Trump to clarify if getting rid of Obamacare meant getting rid of protections for people with preexisting conditions or if he's actually got some kind of alternative which, so far, he hasn't announced.

President Trump: I'm going to put it very simple. We would like to terminate it and we would like to replace it with something that's much less expensive and much better. We will always protect people with preexisting conditions, and here's the thing--

Savannah Guthrie: If you're successful in court in November, those preexisting conditions, that promise will be gone.

President Trump: If we don't succeed, we are running the remnants of whatever's left because we took it apart. We are running the remnants of whatever is left much better than the previous administration, which ran it very badly. We'd like to have new health care, much better and much less expensive.

Brian: With me now to talk about each candidate's stance on what health care the government should and would actually provide citizens in the midst of a pandemic is Julie Rovner, chief Washington correspondent for Kaiser Health News and host of their podcast, What the Health. Hey, Julie, welcome back to WNYC.

Julie Rovner: Thanks for having me.

Brian: For those of you out there who are saying, "I know that name, I know that name," is because she used to be an NPR correspondent covering these same kinds of things. What happens on day zero, Julie, if the Supreme Court does throw out Obamacare?

Julie: Well, there's still some debate about that, but certainly, the money stops flowing. That would be a very big deal. That would mean that people who buy their insurance from the Affordable Care Act marketplaces would still have insurance. They have a contract after all with private health insurance companies, but they wouldn't get any more help from the federal government to pay their premiums. Most of them wouldn't be able to afford it.

The federal contribution to the expanded Medicaid program would also stop, which means that all of those people could still have Medicaid if the state were able to put up the additional 90% of the money that the federal government is now paying for that expanded population. What happens how quickly for all the other pieces and there are many other pieces of the Affordable Care Act is still kind of up for grabs.

The word that most experts I've talked to about this-- and I wrote my first story about what would happen if the Affordable Care Act went away in 2012. The word everybody uses is "chaos." It would throw the entire health system into chaos and not just for the roughly 20 million people who get their care directly as a result of the law.

Brian: Now, the Trump administration claims on the whitehouse.gov website that preexisting conditions were already protected under the Health Insurance Portability and Accountability Act of 1996, so that Obamacare didn't actually create that protection and, therefore, it wouldn't go away. Is that true?

Julie: It's complicated. I've actually spent some time looking into this. I covered HIPAA when it passed in 1996, which is the law that now gives us the privacy protections that it's best known for, but that was a very small part of it. The main purpose of that law was to allow people to go from job-based insurance to job-based insurance without getting caught up in these waiting periods or exclusions if they had preexisting conditions.

Basically, it protected people who were going from one type of employer insurance to another type of employer insurance. There was a provision that let people who were leaving employer insurance and going to buy their own insurance into the individual market to allow them to continue to buy insurance, but there were a lot of loopholes and it turns out those plans were way too expensive for most people. It existed, but it was not a very strong provision.

I have been told and there's some disagreement among legal experts that the Affordable Care Act preexisting condition protections actually wrote through those HIPAA protections. If the Affordable Care Act protections went away, the HIPAA protections would go away also. That is not a universally held opinion. There is some debate about it, but it's at least possible that if the ACA went away, the HIPAA protections would go down with them.

Brian: Treatment for COVID-19 can be extraordinarily expensive as you know with typical hospital bills of almost $75,000 following stays in intensive care unit. Let's talk about how appealing the ACA could affect low-income individuals who become sick with a severe case of COVID, starting with lifting the annual or lifetime limits, which is a whole other category of what Obamacare did. Insurance policies in the past could say, "Yes, you're covered for whatever it covers you for when you get sick, but only up to this total amount."

Julie: That's right. That was very standard in health insurance policies. More the lifetime limits and the annual limits, but some of them would say, "We'll cover you for the first $100,000 of medical expenses." If you have something really bad, too bad. They would also say, "We'll cover you, but only up to a million or $2 million in expenses." Well, if you have something really expensive, that goes on for a long time.

I talked to a lot of patients with diseases like MS. That takes expensive medication basically for your lifetime. You hit those caps pretty quickly. In the old days, if you would, people would have to, again, go from job to job so they could get new insurance with a new lifetime limit. When they reached their lifetime limit, they would have to get a different job with different insurance. It was really difficult and the Affordable Care Act made that all go away.

Brian: Getting rid of the ACA would affect more than 12 million adults who have gained Medicaid coverage through Obamacare. Medicaid in particular was expanded as part of Obamacare and states individually could buy into that expansion or not. Many by now even those with Republican governors that resisted at first in many cases have. What would happen to people on Medicaid if, all of a sudden, the Supreme Court throws out Obamacare?

Julie: That's right. We're down to about only 12 states that have not expanded Medicaid. When the law was passed, it was originally a requirement. In the compromise that ensued in upholding the Affordable Care Act in 2012 at the Supreme Court, the court said that the Medicaid expansion had to be optional for the states, even though the federal government at the beginning for the first three years paid 100% of the costs and it's now phasing down to 90% of the cost.

For regular Medicaid, the federal government pays for wealthier states like New York only half the cost. It was a very attractive financial deal for the states, but what would happen if the law is struck down is that 90% match would stop and go away. The states would be faced with all of these people on Medicaid and, basically, no way to pay for them. State budgets are already terribly strapped by the COVID pandemic mostly because so many businesses are closed and there's no tax revenue coming in. This would be a double or triple whammy of all of these people suddenly facing the loss of their health insurance.

Brian: Is there a Trump alternative?

Julie: Not yet, not that we've seen-- Trump health officials have been asked repeatedly. As you played in the clip, Trump himself has been asked repeatedly if there's a contingency plan if the ACA is struck down. We keep getting told, "Yes, there is, but we won't show it to you."

Brian: What about a Biden plan? He says he wants to make the Affordable Care Act better. Anything that you can put your finger on that would affect COVID?

Julie: Well, mostly protecting the preexisting condition protections. What a President Biden would do, he says, is basically build on the Affordable Care Act with the things that Congress wanted to do in 2010, but either didn't have the money or didn't have the votes to do. One in particular would be to make insurance more affordable right now. Affordable Care Act insurance in the individual market is still pretty expensive even with subsidies and the out-of-pocket payments are pretty high.

Biden is proposing to lower that to make it cheaper for people who are above that four times poverty threshold where the subsidies stop to allow them to pay less, to create a public option not just for people who buy their own insurance, but for people who have employer insurance that's still too expensive. For the people in those 12 states that have not yet expanded Medicaid, all of those people would be covered. Probably, it wouldn't be like Medicare for all. It wouldn't cover everybody, but it would expand pretty dramatically the reach of the current Affordable Care Act.

Brian: Now, Republicans argue that the ACA has made health care more expensive for many people. Here's Senator Ted Cruz during the Senate Judiciary Committee hearings for Amy Coney Barrett last week.

Senator Ted Cruz: Obamacare has doubled the profits of the big health insurance companies, doubled them. Obamacare has been great corporate welfare for giant health insurance companies. At the same time, according to the Kaiser Foundation, average family's premiums have risen more than seven-- risen $7,967 per year on average. That is catastrophic that millions of Americans can't afford health care. It is a catastrophic failure of Obamacare.

Brian: Julie, as a healthcare reporter, can you fact-check that and talk about what has happened to health insurance premiums as a result of Obamacare and what would happen if it went away?

Julie: Yes, I think as PolitiFact would say, that needs more context. He's not completely wrong, but he's conflating a lot of things that don't necessarily go together. Health insurance companies are doing pretty well, but the place where they're doing the best is in Medicare Advantage, which are the private plans that supplement Medicare. They're not making a ton of money on the individual market the Obamacare plans.

Employer insurance is indeed getting expensive. That's partly because health care itself is getting expensive. It's tracking the cost of medical care, which is a huge problem. One thing that is definitely true under the Affordable Care Act is that insurance is more expensive and being able to access care is more expensive than what's anticipated when the law was passed.

There are big deductibles and big out-of-pocket spending for families that, in most cases, have difficulty affording it. Those are some of the holes Joe Biden is proposing to fill because, indeed, that has proven to be a large problem with the Affordable Care Act. It's interesting to see Republicans beating up on profits being made by the insurance industry. That's usually the Democrats' line.

Brian: One of Biden's big plans for trying to get premiums down further is to offer a public option, a government option to Americans premium-free if they qualify for Medicaid but live in a state which doesn't offer it. Do you anticipate that that option would drive commercial insurance prices down for everybody?

Julie: Well, we don't really know. Certainly, that is the hope and the goal. Getting a public option through Congress will be no easy feat. It was in the bill passed by the House in 2010. It couldn't get through the Senate. Unlikely that even if the Democrats take the Senate back, they'll have the 60 votes that were there during the Affordable Care Act debate.

Even if they get rid of the filibuster, there's still going to be some very conservative Democrats who will have a lot of trouble voting for a public option. If it did come to be, it will be an interesting experiment to see how much it pulls down private insurance rates. Certainly, that's why the private insurance industry doesn't love the idea of a public option. They don't really want government competition.

Brian: Last thing, we've got under a minute left. One other highly-popular provision of the Affordable Care Act is allowing children to stay on their parents' insurance until age 26. People forget that that's part of Obamacare. I think people have started to take that for granted. Would that just go away? Would there be a reversion to a different age, 21 or 18 or something if the Supreme Court throws out Obamacare?

Julie: I think that's one of the few things that I suspect would just stay. That would be an option for insurers. It already was an option for insurers. I think at this point, most insurers would probably keep it. It's not all that expensive. As you say, people who use it really value it.

Brian: Julie Rovner, chief Washington correspondent for Kaiser Health News and host of their podcast, What the Health. Thank you very much for joining us.

Julie: Thank you, Brian.

Brian: That's issue 23 in 30 Issues in 30 Days. This begins a run of eight days in a row on coronavirus-related issues. Tomorrow, we'll talk about testing, Biden-style and Trump-style. Brian Lehrer on WNYC. More to come today. Stay with us.

 

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