Trump is reading the GOP base wrong on the Affordable Care Act – Axios

The only plausible explanation for President Trump’s renewed effort through the courts to do away with the Affordable Care Act, other than muscle memory, is a desire to play to his base despite widely reported misgivings in his own administration and among Republicans in Congress.

Data: Kaiser Health Tracking poll conducted Nov. 14-19, 2018 among 1,201 U.S. adults. Total margin of error is ±3.0 percentage points. Poll methodology; Chart: Chris Canipe

Source: Trump is reading the GOP base wrong on the Affordable Care Act – Axios


  1. The problem with the report is that it is based on a poll. Even I am in favor of some of the questions but I know that the questions are lacking details, like how to pay for them. Would I be in favor of free healthcare and unicorns? Yes. I am willing to give all my money to pay for it, no. Well maybe just for the unicorns, that might be more feasible.


  2. The GOP’s mistake is not following up on the failure to pass their own repeal and replace for PPACA 2010.

    The solution was apparent the day Trump took office – leverage provisions of PPACA using the federal government/agency powers, to change how PPACA is positioned, state, by state, by state, starting with Republican led states to create better performing models that include reductions in the premiums employers pay (and employee contribution costs) for health coverage. That would have set the stage for favorable GOP action on PPACA repeal and replace.

    Each Red state would find it the new models to be very attractive as it would reduce the cost of doing business in their state. Most Blue states would, in retaining the existing Medicaid expansion and public exchange structure end up defending PPACA, yet failing to take advantage of PPACA’s waivers.

    I have written about this before, but here is a final, final attempt.

    PPACA §1332 allows for five year innovation waivers of health reform requirements. Social Security Act §1115 allows for Medicaid waivers. While the requirements are highly detailed, the federal agencies have, in the past two years, done their best to highlight the potential of these options. Generally speaking, health reform innovation waivers were available starting 1/1/17 where the covered population is the same or greater, where the innovation does not increase the federal deficit, and where the coverage is at least as comprehensive and affordable as required by PPACA. Medicaid innovation waivers are possible where they improve efficiency, outcomes, resilience, and breadth of coverage. So, innovation waiver pilots must be equal to or better at accomplishing PPACA coverage, affordability and regulatory goals.

    A state pilot leveraging those waiver provisions would automatically provide coverage to 100% of the “lawfully present” population – obviously exceeding the PPACA coverage goals. Because the minimum essential coverage (MEC) and the minimum value (MV) coverage would not include any premium cost to covered individuals, it would meet the affordability requirements and other regulatory goals.

    Here is the model. The coverage would be provided to each “lawfully present” resident of a state without any premium or contribution requirement (funded by the state, state taxpayers, and the federal income tax subsidies for those covered under the public exchange, and those who would otherwise be covered by Medicaid):
    • MEC (required PPACA preventive coverage provisions without any cost sharing),
    • Stop loss in the form of limiting the public exchange to a single option, a default of an HSA-capable health option, with a deductible/out of pocket expense maximum of $6,750 single, $13,500 non-single (2019 levels).

    The stop loss coverage is provided by the state but the coverage on expenses in excess of the deductible/out of pocket maximum is restricted to Medicaid or Medicare reimbursement levels – anywhere from 25% to 50+% below retail, commercial reimbursement rates. No balance billing is permitted.

    Because the coverage is automatic and without any premium/contribution, it always meets or exceeds all PPACA requirements.

    The MEC/stop loss default covers all lawfully present – no one need enroll. MEC and stop loss premiums are paid on a per capita basis charged to each and every lawfully present individual – reconciled on their annual state income tax return. Employers may, but need not allow workers to pay the MEC/stop loss premiums with pre-tax contributions through a cafeteria plan (reported on the taxpayers W-2).

    The state is free to provide other Medicaid options to low income individuals who would have qualified for Medicaid under pre-PPACA and post-PPACA rules. That is, Medicaid / Medicare coverages would retain income/need based premiums, point of purchase cost sharing (dual-eligibles, Part B and Part D point of enrollment (deductibles, copays, etc.) and point of purchase (premiums) cost sharing, as well as Income-based Part B and Part D surcharges, etc.) The state can also waive the MEC/Stop Loss premium.

    Why would this design be successful at reducing costs, including the point of enrollment/point of purchase costs for employer-sponsored plans?
    o An employer would find the cost of coverage to “gap fill” between MEC and stop loss to be much less expensive.
    o Employers, particularly smaller employers, would avoid the impact of catastrophic losses on their insurance premiums,
    o Because 5% of America’s population incurs 50+% of all medical spend, that medical spend will be “controlled” by setting the reimbursement rates at Medicaid or Medicare levels. Providers, physicians, hospitals, medical technicians, drug suppliers would all end up trading off the risk of uncompensated care for certain payment.

    This structure shifts the cost of preventive services and catastrophic expenses to society. That is only appropriate because:
    o The median tenure of American workers is < 5 years, and has been so for the past 5+ decades. So, the requirement to “invest” in preventive medical services typically won’t benefit the current employer and should be born by society.
    o Catastrophic expenses are generally beyond the financial capability of any individual and most employers – so they should be born by society.

    This concept has deep roots in American history and traditions – as former Supreme Court justice Brandeis would say, states are “laboratories of democracy". Let’s allow them to also be “laboratories of health coverage innovation”.

    Feel free to send to your congressperson or Senator in any Red state (with a GOP governor, GOP legislature).

    Based on my almost 40 years in corporate employee benefits, I am confident it will succeed. And, I am 100% certain it is better than existing PPACA crap.


  3. Excellent posting, Mr. Quinn – the only problem with it is that it’s been widely reported that Trump never “reads” anything


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