Personal Reflections on Health Reform, Then and Now (12/15/16)

It’s been a month since the election, and it’s taken me some time to formulate my thoughts.  I’m generally a “cup half full” sort of person, but this has been a tough time.  It’s painful to confront the harsh daily rhetoric about repealing the Affordable Care Act (ACA), especially since I’ve spent the last ten years working hard with so many well-intentioned people to implement this model of health reform.

Coinciding with the election, I faced a strong need for the health care system to work when my father’s health took a dramatic turn for the worse.  For me, there is no avoiding it – our health care system has improved, but it is still broken in many ways.  We don’t have political consensus on what to do next, and yet the fundamental needs that our health care system must address are still there, regardless of who won the election.


There are so many personal stories of people who need health insurance – some who now have coverage and some who still don’t.  I read them and think: “that could be me, or my dad, or my best friend.”  Here are the numbers:

  • There are 30 million people who face losing their health insurance or having severely disrupted coverage due to price increases.
  • You or someone you love are probably part of the 27% of us who are younger than 65 and have a pre-existing condition. As a 50 year old myself, I have more and more friends entering this category.  Without employer-sponsored insurance, we will face the risk of being shut out of insurance coverage, by rules or by cost.
  • Even if you are part of the “lucky 150 million” who have employer-sponsored insurance, no jobs are permanent these days and even the coverage we have continues to erode and get more expensive.


In my ideal world, there would be a true bipartisan approach to solving this.  We had one in Massachusetts – it was called “Romney-care.”  It was the model for the ACA, but the ACA did not get bipartisan support at the federal level.  And with the ACA tagged as “Obama-care,” it probably never will.

So is there any hope of bi-partisan reform?  After years of saying “no” to Obama-care, the Republicans have a chance to craft their own solution.  But it appears that they do not have a consensus within their party.  They have outlined several frameworks (A Better WayEmpowering Patients First ActP-CareAEI’s Improving Health and Health Care), but they still have many holes.  Some proposals, if enacted, would increase the number of uninsured Americans by millions and disproportionately aid the wealthy.  And, Republicans will ultimately need some Democratic support for a replacement ACA option.

Here’s what I think we need to see, for a bi-partisan solution.


We first need to agree on some core principles.  I’d suggest the following:

  • Health insurance coverage should be a shared responsibility for individuals, employers and government
  • Let those with health insurance coverage keep their coverage (including subsidies);
  • Stabilize the individual insurance marketplace and keep it competitive by compensating insurers for extraordinary losses.

There are some good alternatives being generated, such as this report from Brookings.  I won’t go into the details now, but it includes an alternative to the individual mandate, publicly funded reinsurance, some cheaper insurance alternatives, and a simplified employer tax.  It’s a balanced approach, but it still requires public funding.

Which brings me to the question of values.


We can’t make progress on a new version of health reform without clarifying our values.  I’d put providing access to health care at the top of the list.  I believe that it’s an investment worth making, as long as we take some steps to control health care costs.

I also believe in shared responsibility – we all need to pay into the health care system in some way.  At the same time, we need a safety net for extraordinary circumstances and unaffordable care.  So if we don’t “mandate” that people have coverage, then we need to find a way to pay for coverage when people need it.  The ACA replacement options need to include some combination of personal responsibility and an adequate government-sponsored safety net, while ensuring that employers continuing to play their role.


The specifics of how we accomplish all of this may be too hard to do at the federal level, especially considering how politically polarized our country is in some places.  So, this may be something to leave to the states to hammer out, as they best see fit.  An ACA replacement law should provide a flexible framework and sufficient federal funding, and then let states determine their own approach (which could even maintain the ACA in some places).  The federal funding will need to be sufficient to support the principles outlined above, including maintaining the existing levels of insurance subsidies.  These ideas are explored further in this Brookings piece.


Our fundamental needs for health care aren’t going away.  Even those with coverage are more vulnerable than they think.  But ensuring that people keep their health insurance requires fixing the ACA or offering a viable replacement.  Both will cost money.  If we value this as a society, then we need to fix it and fund it.  I believe it’s an investment worth making.