ACP Lays Out Plan to Redesign Affordable Care Act

Marcia Frellick

April 16, 2019

PHILADELPHIA — The American College of Physicians (ACP) wants to strengthen the Affordable Care Act (ACA) by scrapping the cap on premium tax credits, adding a public plan option, and re-enrolling people automatically.

Their recommendations were published online on Monday in a position paper in the Annals of Internal Medicine, just after the ACP Internal Medicine (IM) Meeting 2019.

"So many people are still having trouble finding affordable healthcare. We have to shoot high," said ACP President Robert McLean, MD.

The position paper comes soon after a federal district court in Texas ruled the ACA unconstitutional, which could topple the entire law. Twenty states have signed onto the lawsuit, which is now under appeal.

The ACP calls for the elimination of the cap that currently limits eligibility for premium tax credits to those earning no more than 400% of the federal poverty line ($100,400 for a family of four in 2018) and recommends an increase in premium tax credits for all income levels.

Scrap the Cap

"We need to broaden access to healthcare coverage. We really don't see the need to have that limit," said Sue Bornstein, MD, executive director of the Texas Medical Home Initiative in Dallas, who coauthored the position paper with Ryan Crowley, BSJ, an ACP analyst, on behalf of the Health and Public Policy Committee.

The ACP is also calling for a public option for healthcare so that people have a backup if an insurer withdraws from an exchange in certain markets. A public option also adds competition and provides an alternative to plans that don't comply with ACA regulations.

Just 48% of counties had three or more insurers offering marketplace plans in 2018, down from 58% of counties in 2017 and 85% in 2016, according to the Kaiser Family Foundation.

And in non-Medicaid expansion states, "having a public option really could bring a whole new segment of people into the insurance market," Bornstein told Medscape Medical News.

"Potentially, the public option could be expanded to serve as a stepping stone to universal coverage," Bornstein and Crowley write.

Changing enrollment to an opt-out system would eliminate interruptions in coverage that have been a barrier to wider success, she explained.

Automate Renewals

"There is precedent for this," Bornstein pointed out. "Medicare Part B and D and some Medicaid programs use auto-enrollment."

An alternative might be a late penalty for failing to enroll, similar to the Medicare Part B penalty, Bornstein and Crowley suggest.

The ACP proposals look to be "generally sound," said Linda Blumberg, PhD, a fellow at the Urban Institute Health Policy Center in Washington, DC. Many are in line with Urban Institute proposals, she added.

Discarding the tax credit cap would, in particular, make insurance more affordable "for older adults with modest incomes hit especially hard by age rating under the ACA," she told Medscape Medical News. Of course, additional federal funding would be needed and sources for that are not directly handled in the paper, she explained.

Also not addressed are strategies for expanding Medicaid in all remaining states, although Blumberg said she agrees that is a valuable goal.

"Options include moving to full federal funding of the expansion population's costs, either permanently or for some period of time, in order to further improve the existing incentives for states to participate," she suggested.

Auto-enrollment will be a challenge to design effectively, Blumberg said. There is no master list of uninsured people or those eligible for subsidies, so it will be hard to identify the people who should be auto-enrolled.

"One would also have to decide in which insurance plan or public program to enroll them," Blumberg added.

However, "we think you could do some auto-enrollment of defined populations eligible for no premium coverage and enrolled in other public programs — for instance, the Supplemental Nutrition Assistance Program -– so they are identifiable," she explained.

Reinstatement of the individual mandate is easier and definitely worth considering, she said, adding that some states, including Massachusetts and New Jersey, have put in place their own individual mandates.

And Blumberg said she agrees that a public plan is worth exploring, especially in areas with little insurer or provider competition.

"Another option to get at the same objectives is to cap provider payment rates, both in and out of network, for insurers selling coverage in the ACA-compliant nongroup markets," she said. "This approach could also enhance competition by making it easier for insurers to enter new markets, as they know they would not have to negotiate with providers to get reasonable provider payment rates."

One of the highlighted strategies of the paper is providing money for education and outreach, said McLean, who noted that funding for navigators has been slashed and enrollment windows have shortened, putting people, especially those with low health literacy, at increased risk of falling away from the system.

McLean, Bornstein, and Blumberg have disclosed no relevant financial relationships.

American College of Physicians Internal Medicine (IM) Meeting 2019. Presented April 15, 2019.

Follow Medscape InternalMed on Twitter @MedscapeIM and Marcia Frellick @mfrellick

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