What’s the PPACA’s End State?

Ramesh Ponnuru has a column at Bloomberg View on a piece of legislation offered by Democratic Sens. Mark Warner and Mark Begich:

For the most part, the political debate over President Barack Obama’s health-care overhaul has become a duel between vague slogans: Republicans say they want to “replace” the Affordable Care Act but generally don’t say with what. Democrats say they want to “fix” it but usually don’t say how.

So Democratic Senators Mark Warner and Mark Begich deserve credit for advancing specific legislation to change the law. The main change they’re advocating, though, is unlikely to make people any happier with the law — and could cause new problems.

The senators want to give customers buying insurance on the Obamacare exchanges a new option with low premiums and high deductibles. It would be called a “copper” plan, in contrast to higher-premium, lower-deductible plans already on the exchange (platinum, gold, silver and bronze).

Mr. Ponnuru note, correctly I think, that this is certainly a reform proposal but it’s a reform that solves few problems.

As I read Mr. Ponnuru’s column a question occurred to me: what’s the PPACA’s end state? I have written repeatedly that it’s far too early to measure the effects of the law by which I mean we can’t tell what effect it will have on the proportion of people with insurance, its impact on the insurance industry, or its effect on healthcare costs. I continue to believe that. Much of the law has yet to come into play, it has yet to be enforced, and the law is still facing challenges in the courts. That will probably remain true for the next five or six years at the very least. What then?

As I see it there are several alternatives.

  • The PPACA remains on the books, everybody has health insurance, the PPACA becomes wildly popular, it drives down healthcare costs, and Democrats are elected forever and ever, amen. I think this is a fantasy.
  • The PPACA remains unpopular. Either in the next Congressional session or in the next (Republican) presidential term the law is repealed and, as the Republicans have promised, replaced. With what is anybody’s best guess. I think this scenario too is a fantasy. You can’t step in the same river twice.
  • Subsidies for the states that did not create their own health insurance exchanges are ruled unconstitutional by the Supreme Court. There’s a flurry of outrage and activity but nothing much else happens other than that people in those states (which includes Illinois) aren’t eligible for subsidies. The most notable effect of this is that there’s even less predisposition to enforce the law than there was before. I think this is unlikely—I think the SCOTUS will try to reach some middle ground.
  • The PPACA remains unpopular but also remains on the books, a recurring campaign issue for Republicans and embarrassment for Democrats. Some of its provisions are repealed, e.g. the tax on medical devices, many of its provisions remain unenforced. Healthcare costs continue to rise at an unworkably rapid rate. More people have insurance but a substantial percentage of people remain uninsured. This remains a stable outcome. I think this is possible but not likely.
  • Same as the previous alternative except that the “copper plans” signal the ultimate end state. More plans with lower premiums and higher deductibles are introduced. It’s the death knell of private insurance but the PPACA has left such an unpleasant taste that it is politically impossible to replace or augment it with a “public option”. Most employed Americans of working age are paying an increasing proportion of their incomes out pocket in medical expenses or doing without with adverse effects on health, particularly longterm health. Healthcare costs continue to rise at an unworkably rapid rate.

Let’s put this question on the floor. What’s the most likely life history for the PPACA?

5 comments… add one
  • steve Link

    A key part of many right of center plans is catastrophic insurance. The copper plan might approximate that. Be interesting to see if anyone buys it.

    I think that for the foreseeable future the ACA will remain popular in blue states and unpopular in red states. Nationally the GOP will not put forth a new plan. They will probably try to underfund and defund as much as possible. Its ultimate popularity will largely depend upon the success or failure of those efforts.

    Steve

  • I think that for the foreseeable future the ACA will remain popular in blue states and unpopular in red states.

    I don’t know of any good state-level polling on the subject. Perhaps you do?

    Based on the nationwide polling results your claim seems pretty unlikely. IMO a far greater likelihood is that the PPACA isn’t particularly popular anywhere but is less popular in red states than in blue ones.

  • ... Link

    How about, “Everybody gets Ebola and dies”?

  • Under the “pandemic scenario” the worst that might happen is that everybody would get Ebola and half would die which would be a worse situation than the Black Plague of the 14th century in Europe. Even then civilization didn’t collapse. Whether modern civilization is less resilient than that of the Middle Ages is an experiment I hope we don’t get to participate in.

  • mike shupp Link

    1. The ACA will stick around, in recognizable form, until some significantly more generous scheme replaces it, in maybe 50 years.

    2. Doing away with catastrophic plans was PRECISELY one of the goals of the original legislation, so “Copper” plans are a non-starter. If Republicans manage to get them enacted, as soon as politically possible, Democrats will pass laws that leave the metal names in place but upgrade Copper requirements to what is now Silver.

    3. Expect the expanded Medicaid programs that now exist in Democratic (and some Republican) states to be extended to all 50.

    4. Expect more generous treatment (subsidies) for self-employed and individuals working part-time as time goes on. I’d expect the subsidies to go to individuals with ever higher incomes as well — now 133% of poverty level, 150% of PL in the not too distant future, 200% of PL in maybe 15 years.

    5. The current exemption from providing health care that now extends to firms with 50 or fewer employees will be extended to firms with under 100 employees eventually, then 200. The argument will be made that every firm ought to be exempt, and that health care ought to come out of the government’s general revenues, but I don’t expect this to fly for another 50 years.

    6. That said, I can imagine creation of some very large insurance mass coverage schemes, possibly for providers which don’t exist as yet. Think of something like Kaiser Permanente, which aims at providing health care for say all California DMV workers. Or all affiliated teacher unions in Southern California. Or affiliated police departments in the Washington-Oregon-Idaho region. I can imagine Medicaid clients with no stated preference being steered to such firms. I can imagine large commercial enterprises selecting such providers for their employees. I can even imagine government encouraging this if the costs look good.

    7. Expect more generous funding of hospice care, home care workers for aged, long term nursing care, etc.

    8. Expect a lot of ideas and treatment schemes from other countries to be considered for use, some of which will be implemented. (e.g., robots for assisting care of the elderly, as in Japan) .

    9. I expect a bit more attention to provisioning of high-cost items like motorized wheel chairs. There’s potential for abuse here — Hell, there is abuse — and the hammer ought to fall someday soon. Rather more effective as a cost saver will be increased use of generic and even “old fashioned” pharmaceuticals — QVAR rather than ADVAIR for treatment of bronchitis, for example. I expect to see some effort made to standardize diagnostic procedures and treatment regimes across the nation for at least some conditions.

    10. Some effort will be made to standardize billing procedures and costs. Don’t expect rapid progress.

    11. Doctors are going to get better at providing palliative care for the terminally ill, and more restrained about “heroic” measures.

    12. Hospital cleanliness and prevention of iatrogenic illness is probably fated to be a future issue. Ditto for bacteria becoming resistant to antibiotics.

    13. We’re probably going to put a lot more money into medical research — improved pharmaceuticals, improved psychological handling of the dying and grief-stricken kin, etc. Treatment of Alzheimer’s and schizophrenia is going to be a big big issue.

    14. Successful treatment of patients with some degree of paralysis, those with “locked-in syndrome”, and those in “vegetative” status with some degree of awareness is probably going to be seen as desirable. I.e., this is going to get lots of support and some money.

    15, Fertility treatment for older women will continue to be an issue. Healthcare and monitoring of surrogate mothers may become an issue.

    16. Abortion for fetuses with Downs Syndrome and Tay-Sachs is becoming standard; expect that to continue. Examination of sperm and eggs with the idea of “guaranteeing” the sex and some physical attributes (height, hair color) of children is already a thing; expect the prescribed attributes to eventually include intelligence, immunity from Alzheimers and schizophrenia and other illnesses, and longevity. Currently the cost of producing “premium” fetuses is about 50 to 100,000 dollars; the wealthy can afford this, and it’s conceivable that health insurance companies might offer better rates in the future to such preferred offspring; the great debating topic for the post 2050 period is whether government ought to pick up the tab for all parents who want such treatment.

    Many Republicans will be morally anguished in the course of this experiment. The rest of us will take it with the sort of resignation we afford to social security.

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