Here’s how states can step up and preserve Obamacare


In 2006, Gov Mitt Romney signed a comprehensive health care bill with many political figures present. Front row, l-r Timothy Murphy, Massachusetts Health & Human Services secretary, Robert E. Travaglini, Senate President, Sen. Edward M. Kennedy and Salvatore DiMasi, Speaker of the state House of Representatives.

Despite President Trump’s efforts to repeal his predecessor’s signal domestic achievement, the Affordable Care Act has survived the first year of this vindictive presidency. But it needs help from individuals states as the Trump era proceeds.

When repeated efforts to repeal the law failed, the administration tried to undermine it by reducing the length of the annual enrollment period and the publicity for it. Still, some 8.8 million people enrolled, down less than 5 percent from the 9.2 million who signed up in 2016. Despite the administration’s false and shameful insistence that the law has collapsed, for those who qualify for premium tax credits, the ACA still offers a good deal on health coverage.


Republicans have dealt the law a blow, however, by repealing the individual mandate, which requires those who aren’t otherwise covered to purchase insurance or pay a tax penalty. That change will take effect in 2019, making it less likely that those who don’t qualify for an ACA tax credit will purchase insurance in the future. Republicans obviously hope nixing that requirement will destabilize the individual insurance markets, catalyzing the collapse they have long predicted.

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Insurance markets are an individual state affair, however, which means that state policy makers have the power to strengthen them. Among the actions the states could take: Enact an individual mandate as state law. Currently, Massachusetts, whose Romneycare law was the model for Obamacare, is the only state with such a mandate. That’s obviously a blue-state remedy — but next year there will be eight other states where Democrats control all elected branches of government.

The matter of too many sick people and too few healthy ones in the insurance pools can also be approached a different way: with state-sponsored reinsurance programs, which help cover the cost of patients with expensive needs or conditions, thereby leaving fewer of those costs to spread over the rest of the pool. Result: lower average premiums. Several states are experimenting with that approach.

“Possibly the biggest vulnerability for the ACA right now is the rising cost of insurance for middle-class people buying insurance on their own and not eligible for subsidies,” notes Larry Levitt, senior vice president for special initiatives at the Kaiser Family Foundation. “Reinsurance would help that.” The law even provides an avenue to garner federal dollars to help offset state initiatives like that.

States could undertake their own ACA enrollment-promotion campaigns, and, if they have set up their own enrollment platforms, as almost one-fourth do, hold an extended enrollment period. And they can offer added incentives on top of the federal ACA subsidies. Massachusetts does that; The state “wrap,” as it’s known, has helped boost the percentage of those who have coverage to 97.5 percent, the highest in the nation.


When policy makers dedicate themselves to making a comprehensive health insurance program work, problems can be overcome. But with the federal government’s posture one of not-so-benign neglect, states must step up to make sure millions of Americans aren’t left without decent health care.