Reality Check

The Illusion of Access

While it appears everyone in America has access to health insurance, few can afford the premiums

Recently, a judge determined the Affordable Care Act is unconstitutional, placing one more monkey-wrench in the country’s first attempt at universal health care coverage. The universal coverage promise is failing, mostly because the promises made in passing the act have gone unkept, causing the risks funded by insurance companies to become uncertain, resulting in premium increases.   

For example, the “individual mandate” required everyone to obtain health insurance or face a fine was levied by the Internal Revenue Service. The problem was Congress never gave the IRS the authority to collect the fines other than by siphoning fines from tax refunds. So, if the taxpayer isn’t entitled to a refund and doesn’t get insurance, no penalty applies. Then, because mandates are unsavory to all of us libertarian-leaning folks, President Donald Trump repealed the penalty associated with individual mandate altogether.

Now insurance companies have no way of ensuring healthy people will sign up for insurance. Your insurance premium relies upon a certain number of healthy people to offset the number of sick folks in your insurance pool. Insurance companies taking on the risk of pre-existing conditions can only do so if the young and healthy join the insurance pool. So, in our zeal to ensure folks with pre-existing conditions can obtain insurance, we have forgotten that in order to keep premiums reasonable, we need healthy folks to pay premiums too.

Insurance companies were also promised that everyone who has income above 100 percent of the federal poverty level (FPL) would be in the insurance pool, with the federal government paying all or most of the premiums for folks within incomes between 101 percent and 400 percent of the FPL. This was all well and good, until another part of the ACA – Medicaid expansion – was written in conflict with the FPL subsidy provisions. Under Medicaid expansion, states were allowed to expand Medicaid access to folks who had incomes up to 138 percent of the FPL. The original intent was to expand Medicaid eligibility to 100 percent FPL, but an error in final drafting led to the 138 percent problem. So now folks who fall within the 101 percent to 138 percent FPL are eligible for both Medicaid and for fully subsidized health insurance premiums. So, the 101 percent to 138 percent pay essentially zero under either option, but most choose Medicaid versus paying an insurance premium that is refunded to them at the end of the year.

The ACA is a guarantee of access to insurance coverage, not to health care. Now the access is an illusion. While it appears everyone in America has access to health insurance, few can afford the premiums. In large part, piecemeal gutting of key provisions and failure to edit the contents of the ACA before passage has led us here, and the blame rests squarely with Congress.

Tammi Fisher is an attorney and former mayor of Kalispell.