Understanding the Current Status of the ACA, Future of Health Care

^{By Julie Gould} 

Melissa Andel, vice president of Health Policy at Applied Policy, recently sat down with us to discuss her recent session at AMCP Nexus 2019 and provided a 5-year outlook on where she sees health care moving towards.

Please tell us a little bit about yourself.

My name is Melissa Andel, and I am the vice president of Health Policy at Applied Policy. We are a consulting firm. We work with our clients on market access and government policies.

I work with our pharmaceutical manufacturer clients and help them understand what's going on in DC, especially with regards to Medicare and Medicaid, how that can impact their products, and the patients that they serve.

Can you just tell us a little bit about your session today, why it was important, and what you hope health care professionals take away?

I think the presentation was more of an update on the Affordable Care Act. We spent some time talking about where we are today, with some level setting. I think there's a lot of noise out there, and it can make it difficult for people to really get an idea of what is actually happening out on the ground.

We also talked about some of the major actions that the Trump administration has taken, with regards to health care reform, since January of 2017. We looked at the public's view about several issues with regards to health care, whether that's insurance, prescription drugs, and the cost of health care coverage, how receptive they might be to a Medicare for all or single-payer.

We also did a nice little overview of where some of the presidential candidates stand on health care reform, and then looked a little bit into the future of at least what I think could happen in 2020 and beyond. As far as the key takeaways, I think it's really interesting.

It does look like over these last couple of years, with respect to the exchanges, that market does seem to be stabilizing, from 2019 to 2020. We have not really seen a huge increase in premiums, enrollment among the subsidized population. The households that qualify for premium tax credits has actually gone up a little bit.

While we are starting to see a little bit of an uptick in uninsurance, generally, we are not near the ACA levels. With respect to the exchange market, it does look like that's stabilizing after a rough 2016, 2017, 2018.

Also, I think the other key takeaway is, for everyone to keep in mind—especially with regards to industry, and health plans, and payers—that you start hearing about the Medicare for all, and the single-payer drug price reform, and things like that, and you get a little nervous.

We also talked about, what are some realistic expectations from Congress? What is a realistic way of our path forward, based on what the candidates are saying, but then also what public opinion says.

Please give a five-year outlook. Where do you see health care going?

I think over the next five years, we are going to see that there are some structural issues with the ACA that really need to be fixed. There is a lot of friction. The law requires pretty generous benefits, and then also with the community reading and guaranteed issue, that is something that people like and they want, but that also increases costs.

That is a problem that needs to be resolved somehow. Second, for the households that are buying coverage on the exchange but make too much money to qualify for a premium subsidy, the unsubsidized premiums are quite high and are unaffordable.

I think that Congress will need to look at recalibrating the premium subsidies and making them available to folks above 400 percent of the federal poverty limit, to help them out there. I think that those are two changes that we can see. I think it will also be interesting to see the Medicaid expansion.

Some of the holdout states are going to start to feel a lot of pressure from the hospitals and doctors in those states to expand Medicaid, especially in the more rural areas where it's very pronounced. I think that we will continue to see states expand Medicaid over the next five years.

I really don't think we're going to see a single-payer Medicare for all. A couple of reasons. One, it's probably going to take at least two years to do some legislation on it, and then at least four or five years to implement it after that.

I'm just not convinced that the public opinion is really where it needs to be, to be able to do a whole heart support behind such a radical change for the health care system in the country. Maybe like a Medicare buy-in or Medicaid buy-in, that I talked about that in the presentation.

That is something that has support from the Democrats and Republicans. It's a pretty popular idea. I think that might be something that would also be relatively easy for Congress to look at over the next five years.