Panel: What reporters need to keep in mind as they cover the Obamacare repeal story

Even as President Donald Trump and Republican Congressional leaders take the first steps to dismantle the Affordable Care Act, there’s still much uncertainty about the future of health care in America.

In a Center for Health Journalism webinar this week, leading health policy experts discussed possible replacement proposals and their flaws, and offered suggestions on how journalists can best navigate this huge, fast-moving story. Speakers included MIT’s Jonathan Gruber, an architect of the ACA; American Enterprise Institute's Joseph Antos; and Jennifer Haberkorn, senior health care reporter for Politico.

Haberkorn discussed how the repeal and replace process might play out, putting up an intentionally blank slide to illustrate the lack of clarity at the moment. Observers had initially predicted Congressional Republicans would immediately repeal much of Obamacare through legislation and then debate a replacement.

“Already, that process has changed dramatically,” Haberkorn said.

Now, it appears Republicans plan to repeal as much of the law as they can and enact new policies around the same time, she said.  

Haberkorn highlighted some potential features of a replacement plan, such as tax breaks to help people buy insurance coverage; no or loose minimum standards for health insurance policies; more widespread use of Health Savings Accounts (HSAs); high-risk pools for sicker, more expensive plan enrollees; legalizing the sale of insurance across state lines; changes to Medicaid such as block grants to states; and the retention of pre-existing conditions policy and the provision that allows children to stay on their parents’ plan until they’re 26.

Journalists in states that expanded Medicaid and have Republican governors would do well to examine their respective governor’s response to a potential repeal of the Medicaid expansion: Are they lobbying to keep those federal dollars? She also suggested tracking what happens to the popular pre-existing condition policy, which keeps insurance companies from refusing policies or charging more for people with pre-existing conditions. Is the alternative going to preserve such protections? How will any changes impact those seeking insurance in your coverage area?

Haberkorn advised journalists to carefully monitor the extent to which any new legislation proposed actually replaces Obamacare. “When Republicans say replacement, is there actually replacement in the bill?”

Most action at the national stage will be in the Senate because that’s where the vote tallies are more narrow, and moderate Democrats’ votes will be needed, Haberkorn noted.

Reforming the health system

American Enterprise Institute's Joseph Antos clarified several aspects of what Congress has done so far, and noted the limitations of using a budget reconciliation bill to repeal Obamacare. A separate bill will be required to enact major changes to the Affordable Care Act, he said.

How those changes will play out, though, is still a big question.

While “they all start off by saying ‘Repeal Obamacare’,” the Republicans’ problem is that they have too many plans rather than a single plan, Antos said.

Antos suggested reporters watch for modifications to Medicare Advantage. With Medicare Advantage, the government contracts with private plans to provide Medicare benefits. Currently, people who turn 65 are automatically enrolled in a traditional Medicare plan unless they choose Medicare Advantage. Policymakers could instead ask people to make a choice between the two, rather than defaulting to traditional Medicare.

Antos critiqued Obamacare’s requirement that insurance companies charge the same amount regardless of how much one uses health care services. The government hasn’t done enough action to attract healthy people to insurance plans, which has resulted in a heavy concentration of people with immediate and expensive health needs. At the same time, single healthy people are now able to stay on their parent’s plans until age 26, furthering narrowing the pool of younger, healthy enrollees that might otherwise balance out insurance pools.

Despite some efforts from the CMS Innovation Center, the current system is still struggling with rising health costs, he said: “Reducing costs is the really hard issue and the ACA didn’t address that too much.” When covering these topics, Antos also advised reporters to be clear on executive orders and their limitations. For one, these orders need to be in line with the country’s current laws. And, he pointed out, staff working in agencies such as the Centers for Medicare and Medicaid Services (CMS) cannot “turn on a dime.”  To successfully change direction, career workers several layers deep within CMS will have to show leadership and knowledge of the options.

No realistic replacement to Obamacare

MIT’s Jonathan Gruber dismissed the idea of a feasible alternative to Obamacare, calling the ACA a “massive success.” The health law has increased insurance coverage; stabilized a broken insurance market; prohibited insurance companies from discriminating; and made some progress on cost control, Gruber said.

There’s nothing more conservative than Obamacare that can cover as many people without spending more money, he said. A replacement would either cost more or cover fewer people.

Gruber urged journalists to pay attention to the basic mathematics involved: “Someone has to pay for the sick.”

Under Obamacare’s design, insurance companies bear the burden of covering the sick. They are supported in four ways: The Medicaid expansion, which tends to pull sicker people out of the market; tax credits to encourage healthy people to come into the pool; a penalty for healthy people who don’t join the pool; and through payments to insurance companies to help offset costs of covering the sick.

Republicans have opposed all four policies. Moving forward, they’ll have to change their strong positions, or risk toppling the structure supporting the health system, Gruber said.

Another possibility is simply repealing the law and go back to the old health care world, something he wouldn’t rule out. They could also throw a lot of money at insurance companies to “bribe them to stay in the exchanges,” despite the loss of the individual mandate.

He critiqued proposals such as high-risk pools for people with pre-existing conditions. The only way people in these pools could afford insurance is if they’re massively subsidized, which would likely cost even more than the current system, Gruber said. And proposals such as giving states block grants to manage Medicaid are simply efforts to slash federal funding, he said, not give states more flexibility in how they run their programs.

Speakers encouraged journalists to keep an eye on who takes the blame for the potential repeal of the Medicaid expansion, and any efforts among states to retain or restore those benefits. They also advised journalists to keep an eye on Congressional delegations in areas where there are high numbers of Obamacare enrollees to see if politicians are facing pressure to preserve the ACA’s benefits.

More generally, the panel urged health reporters to look closely at who stands to gain and who stands to lose under any new health care policy.

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Watch the full presentation here: