Enter The New England Journal with a pair of perspectives on the coming prospects for the Affordable Care Act.
Over on the left, the Brooking Institution's Henry Aaron believes that, notwithstanding ascendant Republican hopes for the 2014 elections, Mr. Obama's veto power virtually guarantees the law's survival. The only question is whether politics will get in the way of any adjustments. Once we're into 2015 and beyond, these could include the mandate (weaken any penalties?), Medicaid (spending caps?), the states' roles (allow for local modifications?) and changing affordability standards (increasing income-based premium support for families).
Over on the right, the American Enterprise Institute's Joe Antos agrees there is no going back. He offers up some potential conservative modifications for 2015 and beyond, such as shifting the insurance premium support to a defined contribution basis (versus a defined benefit), shielding mainstream health insurance by moving catastrophically ill persons to "high-risk" pools and requiring insurers (including Medicare) to leverage consumer education and incentives along with provider teaming to help steer beneficiaries toward lower-cost care options.
Drs. Aaron and Antos both agree that IRS-based enforcement rules may force significant changes. Under current law, poor persons who underestimated future income for today's premium support calculations may be subject to claw-backs. According to Dr. Aaron, the IRS is responsible for administering that, and any payment would ultimately go to the insurer long after the fact. Dr. Antos points out that the IRS's enforcement of the mandate could lead to the spectacle of tax refunds being withheld from low-income individuals and families.
The PHB is less sanguine. While the PHB is no political pundit, the likely increase in the number of Republicans in Congress after 2013 combined with the kick-off of the 2016 Presidential race portends more of the same health reform gridlock.
The only good news from Aaron and Antos is that growing antipathy toward the IRS may lead Congress to uncouple the IRS and it's enforcement mechanisms from the ACA. It may not be an example of pristine bipartisanship, but if it leads to necessary modifications of the ACA, that's not necessarily a bad thing.
Stay tuned!
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