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WSJ: Stand Up for ObamaCare, CEOs

This article originally appeared in The Wall Street Journal on Jan. 3, 2017 7:08 p.m. ET 

By Annie Lamont and Ezekiel J. Emanuel

One company’s managers think repeal would raise its health-care costs by hundreds of millions.

America’s CEOs might not admit it in public, but the Affordable Care Act—aka ObamaCare—has been good for business. Company benefits managers have watched as the double-digit premium increases under President George W. Bush slowed to a crawl. Venture funding has flooded into health care, boosting startups and stimulating innovation. This is the progress President Obama is trying to preserve as he meets Wednesday with Democrats on Capitol Hill in a strategy session about how to protect the health law.

To take a single benchmark, look at families who receive insurance coverage through an employer. Between 2001 and 2008, their average premium jumped nearly 80%, according to annual survey data from the Kaiser Family Foundation and the Health Research and Educational Trust. Under President Obama, the increase was only 36%. This represents real money: If the Bush-era rate of inflation had continued through 2016, each of these families would be spending about $5,000 more on annual premiums. For employers, the savings open the door to hiring more workers or raising wages.

At the same time, investment in medicine has boomed. Between 2011 and 2015, venture funding for health care—including biotechnology and medical devices—totaled approximately $62 billion, according to figures from PitchBook. In the four years before the Affordable Care Act, the total was $47 billion. New companies are working to improve everything from primary care, to home palliative care, to the management of mental health. These innovations are now beginning to realize cost savings.

The Republican plan to repeal and replace the Affordable Care Act threatens to reignite health-care inflation. First, this approach produces significant uncertainty in the market. The GOP has promised immediate repeal, but the talk of what would replace the health law—and when—is vague. “I don’t want to set a time limit that this has to get done by this certain date,” Rep. Kevin McCarthy, the majority leader, said in late November.

It is easy to repeal ObamaCare’s subsidies and the mandate to buy insurance, since that can be done with only 51 Senate votes using the “reconciliation” procedure. But enacting a replacement is harder, maybe impossible, since it would require 60 Senate votes to overcome a filibuster. Insurance companies hate uncertainty and respond by raising rates to hedge their risk.

A second problem is “cost shifting.” If Republicans repeal and replace the Affordable Care Act, millions of Americans will probably lose their insurance. The replacement proposal offered by House Speaker Paul Ryan would lead to four million fewer insured people by 2026, according to a review by the Center for Health and Economy. Nine million could lose coverage under the replacement plan offered by Sen. Richard Burr, Sen. Orrin Hatch and Rep. Fred Upton, according to scholars from Rand Corp.

The bulk of these newly uninsured would be low-income Americans who can’t afford private coverage despite the tax credits built into Republican plans. But such people will still be treated when they get sick. Though they cannot pay for it, they will still receive care at hospitals, urgent-care outlets and doctors’ offices. These costs will be rolled into the line item “uncompensated care”—which is ultimately paid for by higher prices on everyone else.

The Affordable Care Act has helped minimize this cost shifting. Specifically, the law’s expansion of Medicaid cut hospitals’ uncompensated care by roughly a third from 2013 to 2014, according to a study in Health Affairs. At the University of Pennsylvania Health System, bad debt—the accounting term for bills that are written off when patients can’t pay them—decreased from 6.1% of revenue in 2014 to 3.9% last year. Taken nationally, a drop that size is worth nearly $25 billion a year.
The GOP’s plans will reverse these incentives. Republicans want to send Medicaid back to the states using block grants. More important, they want Washington’s contribution to Medicaid to grow more slowly than the actual costs. A 2014 analysis by the Bipartisan Policy Center estimated that Rep. Ryan’s plans to block-grant Medicaid would reduce federal funding for the program by $160 billion in 2022.

State legislators are likely to respond in two ways. They can tighten Medicaid eligibility to reduce the number of recipients, which will increase the ranks of the uninsured. Or they can cut the rates that Medicaid pays to hospitals and physicians, who would make up the difference by increasing prices on everyone else.

Critics of the Affordable Care Act argue that when previously uninsured people gain coverage through Medicaid, they tend to use expensive emergency-room services. But people who have just gotten coverage can’t be expected to become sophisticated health-care consumers overnight. The use of the ER suggests they have unmet medical needs. Over time they can be educated to develop standard relationships with physicians. Even factoring in this greater use of ERs, however, the per person costs of Medicaid have decreased since 2010 after adjusting for inflation.

Businesses know all this. In response to the GOP’s call to “repeal and replace” ObamaCare, one Fortune 100 company with hundreds of thousands of employees is developing two HR budgets. The first reflects the status quo. The second factors in the higher prices Americans will face if more people become uninsured. Although these estimates aren’t final, the company thinks its health-care costs could rise by tens of millions of dollars in a single year if the Affordable Care Act is repealed and replaced.

President Obama’s health law really has been good for business. Republicans’ plan to dismantle it will take the country back to an era of high health-care inflation. If only CEOs would say as much before it is too late.

Ms. Lamont is a managing partner of Oak HC/FT, a venture fund investing in health care and financial services. Dr. Emanuel is vice provost for global initiatives, as well as chairman of the Department of Medical Ethics and Health Policy, at the University of Pennsylvania.

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