A federal judge’s ruling that the entire Affordable Care Act (ACA) — Medicaid expansion, subsidies through the exchanges, Medicare reforms, everything — is unconstitutional shocked the political world last Friday.
The case had already been appealed, of course, and we can expect it to wind its way through the courts, perhaps even to the Supreme Court, in the months and years ahead. Legal scholars — of which I am not one — seem to question the grounds of Friday’s ruling, and it could easily be overturned by a higher court, defusing the threat to the ACA.
Whether final adjudication will come before the 2020 presidential election is anyone’s guess, but perhaps the mere possibility of the ACA’s disappearance before the end of President Trump’s term will motivate him and his Republican allies to redouble their efforts to pass a serious, free-market-oriented replacement plan. That task will become substantially harder with Nancy Pelosi in the House Speaker’s office, of course, but Democrats could pay a heavy political price for appearing obstructionist if the public believes the ACA’s demise is imminent.
The fear of political backlash from stripping 20 million Americans of health coverage without a robust replacement may compel both parties to cooperate in a way that was utterly absent from the bitter wrangling of the last health care debate in early 2017.
As federal policymakers grope for a bipartisan solution, Maine’s historic insurance reforms in 2011, known as PL 90, are likely to take center-stage as a model for national policy.
PL 90 rolled back many of the regulations put in place under Governor Baldacci’s Dirigo Health program, which contained many provisions that would later be adopted in ObamaCare. PL 90 loosened community rating regulations, allowing the free market to determine premium rates more fairly. It also guaranteed access to reinsurance funding to high-risk individuals (a key subject in congressional health care debates), legalized the purchase of insurance across state lines, and made it easier for the long-term unemployed to buy health insurance.
The legislation’s effects were clear. In the years following PL 90’s enactment, average annual premium rate increases in the individual and small group markets slowed (and sometimes reversed). Freed from burdensome regulations, insurance companies began offering new, more affordable plans more closely tailored to their customers’ needs.
PL 90 achieved stability and lower prices in the private health insurance market while retaining protections for high-cost individuals who could not afford insurance in a fully free market.
If lawmakers are looking for a successful state-level model to apply nationally, they should look no further.