Repealing the ACA

As a former Medicaid Director for a large eastern state, I would like to make the following recommendations on how to repeal and replace the ACA, ObamaCare, (Yes, Virginia, in a press conference our current President actually said he likes that the ACA is called Obamacare, "I do care." August 2011).

Here are my suggestions for how to succeed.  These and $5 may get up a cup of coffee at Starbucks.

On Medicaid Expansion:

• Discontinue marginal adjusted gross income (MAGI) for eligibility,  This income test requires a look back to confirm the income, and does not consider assets in the calculation,  One could literally have $1M in an trust account that pays all ones bills, but only yields $1000 per month spending change and qualify for Medicaid,
• Do not return to the days of requiring that a person live in a family with children to recieve Medicaid,  Income and assets should be the only determinate of eligibility (Prior to the ACA, single adults and couples without children could not qualify for Medicaid unless aged, blind or disabled).
• Allow tailoring of benefit packages to meet the needs of eligibility groups.

On Insurance purchases:

• Allow purchases across state lines
• Create pools or other mechanisms that guarantee issue for those in good health with preexisting conditions
• Do not reinstate lifetime/annual maximum benefits
• Allow individuals and groups to have more tailored benefit packages (i.e.--really I don't need or want to pay for transgender surgery or abortions) If contraceptives are important to you then buy a rider
• Discontinue high deductible plans unless the individual has the ability to participate in a Flexible Spending Account or Health Saving Account 
• Allow copay health plans again
• Define preexisting conditions by health status not by diagnosis

Just some thoughts.  Know that if the pricing is fair and weird requirements such as no plan can cost more than 4 times the lowest cost plan, more young people would buy in at a reasonable rate. As person with a preexisting condition, married to a person with a preexisting condition...I am anxious to see what comes out, but I understand the need for some ability for costs to reflect the health status of the individual.

The Future Meets Regulation and Fails

In the 1980s, as a newly minted Medicaid executive, I went to the Arizona town of Arcosanti.  Arcosanti was Architect Paolo Soleri's dream city meant to be eco-friendly, innovative and composed of a single structure.  The structure would be a laboratory for self-sustaining and self-contained  cities of the future. Arcosanti was meant to house 5,000 people, but to date, 47 years since its inception, it houses only 100.

What happened?  The dream met the  reality of government regulation and failed to thrive.  How often does this happen? Nothing has been built in Arcosanti for over 15 years.  Why? According to David Kidd in Governing Magazine, January 2017, "That's partly the fault of new building codes--the local fire company has put a halt to any additions until the dirt road that leads from the nearby interstate is paved."

Total government control is never a good thing. In picking the alternative energy winners and losers, being self-contained and self-sustaining is not a good thing.  One wonders what alternative the local fire company discussed with Arcosanti in terms of delegated responsibility, versus literal adherence to the letter of the law. Prehaps its funding from donations and the sale of Arcosanti Bells makes it just a little too independent for governement to work with.

I wonder how different the end of this story would be if Arcosanti were dependent on gvernment grants and alternative energy development?