Some simple changes to improve ACA (Part One)

Here are some simple “fixes” that would reduce confusion over ACA provisions, help further the individual goals of the statute, and possibly improve the efficiency of signing up ACA customers, and the reason why they are needed.

1) Eliminate the Medicaid gap for non-expansion states: The ACA provides that  taxpayer units (individual or joint followers) are eligible for premium assistance tax credits when household income is between 100-400% of the federal poverty line. At the time of drafting, it was assumed that all any person with income under 100% of the FPL would be enrolled in Medicaid, as the terms of the original statute essentially mandated expansion in all states. (States which did not agree to expansion would have faced loss of federal funds).

However, after the US Supreme Court struck down the Medicaid provisions, half of US states opted out, meaning that individuals who earn less than the FPL who live in those states are not eligible for subsidies on the exchanges.  This leaves many of the neediest individuals out in the cold, and undermines the central goal of ACA: to provide insurance for all.
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Who’s Left Out? (Part One)

The goal of the Affordable Care Act is in its name: to give every American an affordable option to buy health insurance.  

Unfortunately, there are two groups of people who may find themselves left out, and stuck with no affordable option. 

One group are the adults with household incomes of less than 100% of the poverty line.  When the law was written, it included a massive, federally funded expansion of Medicaid, guaranteeing that all adults with poverty-level incomes would be enrolled automatically in Medicaid.  In fact, under the expansion, the cutoff for adult eligibility for Medicaid rose to 138% of the poverty line. [1] (Children were already eligible through passage of earlier laws).

Because that group was guaranteed care through the government-run program, they would not need to pay for premiums on the exchange, nor would they need subsidies.  So eligibility for subsidies was restricted to those with incomes between 100% and 400% of the poverty line.

However, in 2012, the United States Supreme Court ruled that the Medicaid expansion part of the ACA was unconstitutional.  The problem was that Medicaid is administered separately by the states, and Congress had written the law as a take-it-or-leave-it proposition that punished the states who didn’t sign on. If the states agreed to the expansion, they received a massive influx of federal funding to support the new programs.  But if they turned the federal government down, they would lose their already existing federal funding for the more limited Medicaid programs already in place.  Continue reading