Sen. Susan Collins deserves credit for putting together an alternative to the Affordable Care Act, which many of her Republican colleagues promise to soon repeal, with or without a replacement plan. Her proposal, crafted along with Louisiana Sen. Bill Cassidy, would turn over much of the insurance program to the states. This raises many questions about whether and how residents will be insured — and the quality of their coverage.
Essentially the plan gives state three options: Keep the ACA, reject the ACA and decline all associated federal funding, or craft an alternative insurance program to be funded mostly by the federal government. It would take affirmative state action to opt out of participation in the new ACA alternative plan, although what that action is — a vote in the Legislature, a letter from the governor — is not spelled out in the bill. So, in Maine, where the governor is no fan of the ACA (or its provision allowing for Medicaid expansion), it is unclear what path would be taken even if the majority of current participants in the state’s health insurance marketplace wanted to keep the insurance they currently have.
The bill contains many positive provisions — which happen to be some of the more popular aspects of the Affordable Care Act — such as prohibiting insurers from excluding people with pre-existing conditions and continued coverage for mental health and substance abuse. For states that continue participation in the Affordable Care Act, residents would automatically be enrolled in a low-premium, catastrophic plan, rather than face a mandate to buy insurance. This is an alternate strategy to seek large and diverse enough pools of participants to keep insurers in the market.
But, there are worrisome provisions as well. The plan that involves states rejecting the Affordable Care Act but not its funding relies on health savings accounts and tax credits, long touted but unsuccessful Republican solutions to extending insurance coverage. The proposal eliminates some of the essential health benefits that Affordable Care Act-compliant plans must provide. The absence of these threshold requirements throws into the question the quality of coverage insurers would offer. And the Collins-Cassidy plan only indirectly tries to address real problems with the ACA, such as rising premiums and the exodus of insurers from the program.
So far, the proposal, unveiled Monday, has garnered little support inside and outside of Washington, although Sen. Lindsey Graham, R-South Carolina, signed on as a cosponsor Wednesday, joining Republican Sens. Shelley Moore Capito of West Virginia and Johnny Isakson of Georgia.
Many conservative lawmakers will not support Collins’ plan. They simply want to repeal the ACA because they don’t believe the federal government should be involved in health insurance. They are not interested in an alternative, nor do they appear troubled by the immense human and budgetary consequences of a repeal.
Democrats in Congress, along with health care providers and activists, believe the bill falls far short of what is needed to prevent millions of Americans from losing affordable, comprehensive insurance coverage. But, a Democratic-sponsored bill would have little traction in the Republican-controlled Congress.
Here’s how long-time New York Times health care reporter Robert Pear described the conundrum: “[T]he plan was attacked by Democrats as a step back from the Affordable Care Act’s protections, and it was unlikely to win acceptance from conservative Republicans who want to get rid of the law and its tax increases as soon as possible. If anything, the proposal…may show how difficult it will be for Republicans to enact a replacement for the Affordable Care Act.”
Collins is to be commended for trying to thread this needle. Beyond the difficult politics, there are many details that need more attention, especially how the finances of the Patient Freedom Act would work, both for states and for individuals covered by the new plans.
Their current bill is nowhere near an acceptable final product, which its authors acknowledge, but by putting forward a new approach, Collins and Cassidy have opened the door to bipartisan discussions of what an ACA replacement plan could look like.