Data Graphic: What’s Easy and Hard About Changing the ACA

Another name - not Trumpcare.

Republicans and POTUS overlook that substantial desirable changes can be made to the ACA via regulation (I know how to do it).
HHS (or Congress) can change essential benefits, eliminate the mandate (e.g., define everyone as covered), change copayments and deductibles, change subsidies, provide huge financial incentives to encourage capitation (e.g., low premiums, low total cost), create incentives for lifestyle likely to achieve best population outcomes (e.g., diet, free AK47s (reduces CAD deaths), no smoking. Example: weight loss is often better for high cholesterol than enzyme inhibitors. There are a wide range of behavioral and financial incentives available via regulatory policy that can imitate most of the changes proposed by Congress. See my comments at http://healthaffairs.org/blog/2017/01/10/to-get-dems-on-board-with-aca-replacement-republicans-should-take-medicare-off-the-table/
Eliminating the mandate will not necessarily increase insurance premiums if we reduce inefficient care and create low premiums policies to cover individuals willing to made substantial lifestyle changes and higher premiums for those who prefer expensive drugs (or drinking, smoking, risky sports, crime, etc.). As other posts noted, suboptimal quality of health care accounts for about 10% of premature mortality in the US; 40% is due to behavioral determinants of health (and my research indicates that environmental chemical pollution accounts for huge %). See www.nejm.org/doi/full/10.1056/NEJMsa073350
Transforming Medicaid into a massive capitation program via fixed capitation payments to states follow the concepts behind the development of HMOs in the 1970s. I was responsible for analyzing the behavior and economic consequences of replacing fee for service with capitation (HMOs) in the U.S. My analysis was used by the executive branch in its official submission to Congress. I was hired by HEW, now HHS and OMB and created mathematical models of the U.S. economy and alternative health reimbursement methods. The administration planned to transform entitlement health programs into capitation, mandating or encouraging HMO enrollment (via premiums and other financial incentives). This is not necessarily bad. There is too much inefficiency, waste and fraud in health care. With appropriate competent, expert supervision and uniform national guidelines, capitation can do better than the current system to improve desirable outcomes (morbidity = wellness + mobility, and mortality = life expectancy). The riddle is whether Congress + POTUS improve ACA/voter’s health, or voters improve Congress + POTUS.

In my opinion the problem with the Affordable Care Act (ACA) is that it groups a large number of high-cost patients with a few private-paying and government-sponsored or subsidized patients. In order to make this profitable for insurers, this has required: high premium costs, high deductibles, and large out-of-pocket costs for patients. None of which are "affordable." The only people who have benefited from the ACA are those the government paid for or subsidized or those whose insurers previously would not cover. To make this plan work you must have a large body of "healthy" or low-cost patients to offset the high-cost patients. I would recommend that this group would be all who are employed by federal and state government, as well as military personnel and their families. With this as the base, allow anyone who wishes to purchase insurance through the current federal insurance plans. This would cause a rise in federal and state employees' insurance costs, but should significantly decrease the costs of what people in the current ACA plans are paying.