PHILADELPHIA — Many healthcare industry leaders believe the Affordable Care Act is too deeply entrenched to be repealed, as Republican presidential candidate Donald Trump and his party promise to do.
But in the Democratic National Convention's only public discussion on healthcare policy, architects of the Affordable Care Act Wednesday warned he and congressional Republican leaders could indeed abolish key elements and roll back the insurance expansions and consumer protections.
Their comments came during a panel discussion sponsored by the Democratic Party-affiliated Americans United for Change. It was attended by a who's who of Democratic-affiliated health policy leaders and wonks, including acting CMS administrator Andy Slavitt and former CMS administrator Marilyn Tavenner, who now heads America's Health Insurance Plans.
The Republicans would use the budget reconciliation process to repeal the premium subsidies and Medicaid expansion, said Ron Pollack, executive director of Families USA, whose group helped build support for the law's passage. Under budget reconciliation, Senate Republicans would be able to evade a Democratic filibuster and pass these major changes with a simple majority vote.
Chris Jennings, who worked as a senior health policy adviser to the Obama administration during the drafting of the law, said people are wrong to think the ACA can't be repealed. After running for years on promises to repeal the law, Republicans will have to take strong action if they win the election, he said. They will particularly target Medicaid, not just eliminating the ACA's expansion to low-income adults but rolling the program back from pre-ACA levels. “It would be a crazy different world,” he said.
The discussion, which included former Senate Majority Leader Tom Daschle, former White House health policy adviser Nancy-Ann DeParle and former Hillary Clinton senior aide Neera Tanden, was the only in-depth health policy discussion scheduled in Philadelphia during the Democratic National Convention. During the convention itself, the only detailed – though brief-- health policy comments from a speaker came from Vermont Sen. Bernie Sanders, when he touted presidential nominee Hillary Clinton's healthcare agenda Monday night while endorsing her.
The Democratic convention has been a “policy-free zone” for healthcare discussions so far, Jennings said in an interview. “People want to hear who Hillary Clinton is, not what her policies are,” he said. “They already know she knows a lot about policy.”
Several of the speakers see the possibility that if Clinton wins the election, congressional Republicans will grudgingly accept that the ACA is here to stay and be willing to make deals to improve it.
Daschle, now a Washington-based policy adviser, stressed the need to improve the functioning of the ACA's exchange markets for individual insurance. “We have to be honest about the viability of the marketplaces, we're not out of the woods,” he said. “We have to bring in more healthy people, make risk-adjustment payments to insurers, and emphasize people's personal responsibility for their own health.”
Pollack said a Clinton victory would “open space for dialogue” on incremental improvements in the law, such as encouraging health plans to cover certain services, such as care for chronic conditions, without applying the deductible.
But he and the other panelists avoided talking about potential bigger deals between the Clinton administration and congressional Republicans. Former Congressional Budget Office director Douglas Holtz-Eakin's suggested in an interview that Clinton could offer states much greater flexibility on Medicaid in exchange for GOP support for ACA funding and continued Medicaid expansion.
Pollack said he didn't see that as likely, because the Clinton administration would continue the Obama administration's policy of establishing “guard rails” to protect Medicaid eligibility and minimize premium payments by Medicaid beneficiaries. That would be endangered, he said, by granting states overly broad flexibility.
Despite the highly visible presence of Sanders supporters wielding “Medicare for all” signs during the convention this week, the only mention of the challenger's health policy agenda came when Jennings touted the Sanders-backed platform proposal to allow people 55 and older to voluntarily buy in to Medicare. He said that could help the Medicare risk pool by attracting healthier members. “That's exactly the direction we should go in if the exchanges aren't providing adequate choice,” he said.
Clinton, if she's elected, will continue to face pressure from single-payer supporters even as she fights to make healthcare improvements in the face of Republican resistance. “The single payer people aren't going away,” Pollack said. But they need to remember a lesson often cited by the late Sen. Ted Kennedy: “The perfect can't be the enemy of the good.”