Could the candidates truly fix – or nix – Obamacare? Six essential reads

Editor’s note: The following is a roundup of archival stories related to the Affordable Care Act, more commonly called Obamacare.

Hillary Clinton and Donald Trump disagree on many, if not most, issues, and how to provide health insurance coverage for Americans is one of the most divisive. Clinton’s first foray into national politics began with her failed attempt to devise a plan for health care coverage, and she has long been linked in many people’s minds to that failure. Trump’s main position on the ACA is straightforward: Repeal it.

There is no doubt that the law is facing troubles that are not just political. Most notably, a number of insurers have exited the health insurance marketplaces created by the ACA, and consumers now face double-digit premium increases in the new open enrollment period that begins Nov. 1.

The law came up in Trump’s last answer of the final debate last night. When Chris Wallace asked how the candidates would control the rising costs of entitlements, Trump said repealing the law is key. Clinton strongly disagreed.

“Repeal and replace the disaster known as Obamacare,” Trump answered when asked how to control the costs of entitlement programs. “Obamacare has to go… She wants to make it even worse.”

“If he repeals it, our Medicare problem gets worse,” Clinton said in response.

More insured

The Affordable Care Act is complex and complicated, mixing government mandates and oversight with marketplace forces. The goal, however, was simple: Decrease the number of uninsured across the country.

On that score, economists Jim Marton and Charles Courtemanche at Georgia State University explained recently that the law has indeed broadened coverage to many Americans, writing:

“If you look at our numbers, however, it is hard to escape the fact that it has helped 20 million people over three years gain insurance coverage – one of the law’s primary objectives.”

Premium hikes

But, Trump’s point about rising premiums is also hard to ignore. J.B. Silvers, an insurance and health care financing professor at Case Western Reserve University, explained that the premium hikes were due, in part, to a flaw in how the law was written. Silvers wrote that the law’s design has allowed Congress to block funds to insurance companies that would limit their losses. Thus, the companies are forced to raise premium prices to make up for those losses.

“Because Congress has only allowed 12 percent of the amount due to insurance companies, the premium stabilization features have been insufficient to limit losses as the law envisioned. This gap was not anticipated in prior year rates by insurers, but it is built into the premiums this year. That’s part of the reason for the increases.”

Rationing health care?

While the administration has extolled its virtues and successes from the outset, Philip Rosoff, director of clinical ethics at Duke University Hospital, saw flaws from the first, including the marketplace forces that have led to insurers’ losses. Rosoff saw those forces as a drawback not because they would cost the insurers but because they would create a profit motive that should be disentangled from the system.

“The ACA builds upon our existing health insurance system in many ways. And, thus, it represents a gift to all of those who seek to profit from the health and illness of others.”

Trump’s alternatives

During the Republican National Convention, Trump talked less about health care than many other of his signature collection of talking points, such as immigration, China and terrorism.

In addition to calling for a full repeal of the law, Trump wants to allow insurers to sell across state lines, which he believes will cut costs. Bill Custer, director of the Center for Health Services Research at Georgia State University, offered this analysis of that piece of Trump’s health care plan:

“In 2011, the state of Georgia was the first state to pass a law similar to this proposal, but it has not found insurers willing to offer this coverage. At least 20 other states have since followed suit, but insurers are not sure they want to do this. Numbers are not available on how many insurers have applied in various states, but it is safe to say that the idea has not been popular.”

As for overturning the law, John McDonough, professor of public health practice at Harvard, wrote in March that repeal would be impossible without a full Republican takeover of the presidency, Senate and House.

Clinton’s public option

Clinton, meanwhile, has not given a lot of specifics on the parts of the law that need treatment.

Insurers pulling out of the marketplace and rising premiums for consumers are the two biggest issues. Richard Hirth and John Ayanian, health care policy experts at the University of Michigan, explained how Clinton’s proposals for a public option could be one way to help consumers deal with the rising costs. Yet, just as others note that Trump would have trouble in repealing the law, they note that Clinton would have trouble in passing a public option.

“The public option would further the primary goal of the ACA by expanding health insurance to as many Americans as possible, by offering an additional coverage option not currently available. But given Congress’ historical opposition to the public option and the ACA, the most likely route for public health insurance would be through states.”