Last night I gave a talk at a community gathering in Princeton. My topic was: Repeal, Replace, Reform: where the ACA is going and how it impacts you. Back in August, when I agreed to give this talk and created this title, I was planning to talk about ACA fixes to make health care affordable. I did not expect that, come December, I would be speaking about repeal and delay to a packed room of more than 100 people. The prevailing mood was concern — and uncertainty.
Uncertainty and insurance do not mix well. Insurance is based on being able to predict what will happen and to price accordingly.
Now that the election is over, we have to accept that President-elect Trump and the incoming Congress ran on a promise to repeal the ACA and that they will make good on that promise. That is fair. But, as someone who thinks a lot about health care and health coverage, I urge our nation’s elected leaders to proceed in a thoughtful way that reflects the trust the electorate has placed in them. To me, the most important leadership quality is the ability to solve problems for my community. Leaders should not look to make quick headlines or to obtain the instant gratification of a win just for the sake of it. They should instead try to solve, advance, or improve the lives of their constituents.
Right now, the President-elect and newly elected Congress have that choice. Do they move forward with the idea of repeal and delay? Whether the “delay” is pushed back for a few months or years does not matter if they do not have a plan for replacement. A repeal without a replacement plan is a failure of leadership. It brings uncertainty and chaos to 18% of our economy, and, more important, puts people’s lives and health at risk. Repeal without a replacement will destroy insurance markets starting in 2018. And, the lack of a replacement of the ACA impedes our effort to move forward with the difficult work of providing patient-centered care that improves quality and reduces costs.
Recently, Congressional Republicans reached out to states for ACA replacement ideas and sent a letter to Governors and State Commissioners of Insurance across the country inviting them to a meeting in early 2017 to get to work on the replacement plan. This is the right approach, and one that I call: Reflect, Repair, Repeal, Replace.
Before the ACA is repealed, there should be a replacement plan in place that has been reflected upon by all of the stakeholders, especially the states, as the new administration has stated that it intends to turn much of the oversight and decision making back to the states. Indeed, a thoughtful replacement plan may foster needed repairs and new ideas across the country.
New Jersey has some advantages if oversight is returned to a state-based system. Before the ACA, most states allowed insurers to consider health status when selling and pricing insurance. New Jersey did not. We only allowed plans to use region and age, except for the basic and essential plan, which also used gender. We could reinstate and revert to NJ regulations. But an ACA repeal would also present significant economic challenges to our state budget, as there is no immediate source of state funding for premium subsidies, maintaining Medicaid expansion, or reinstating charity care funding.
We must get to work on the reflect and repair stage now. State leaders must pay attention to what is coming. Fiscal analysis should be done immediately to model all potential scenarios. Regulations should be reviewed to identify all necessary changes.
Years ago, the Quality Institute worked with state leaders and our members to design needed changes to our insurance markets and Medicaid program. We will continue this work through our board of experts and multi-stakeholder membership. We are already hard at work, through funding provided by The Nicholson Foundation, to create a blueprint for an improved NJ Medicaid program. With you, our members, we will formulate ways to keep people insured and advance the quality and affordability of health care for all. We have no time to waste.