EDITORIAL: Repeal is easy. Replace the Affordable Care Act? That’s hard

Nov. 21--During the campaign, Donald Trump joined the call for repealing and replacing the Affordable Care Act. The now president-elect even talked about taking action on day one of his administration. Of late, he has hedged, arguing some parts would be kept, in particular, the requirement that insurers cover those with pre-existing conditions.

That is a welcome change. In Ohio, roughly 900,000 people have gained health insurance under the act, either through the Medicaid expansion or the exchange where insurers offer coverage to those buying on their own. The exchange includes subsidies to help make policies affordable.

Worth emphasizing is that protection for pre-existing conditions is part of an intricate layering. Establish that guarantee, and other things must follow, providing insight into why the Affordable Care Act is so complex.

The pre-existing condition pledge means higher costs for insurers. Thus, they need a hedge against risk. It comes most dramatically through the individual mandate. That brings healthier people -- and their premiums -- into play, providing the revenue stream that allows insurers to keep pace with the higher cost of covering the chronically ill.

Such complications could be avoided by, say, expanding Medicare, the single-payer system for seniors. That is not politically doable. So the Affordable Care Act involves a mix of market mechanisms and regulations to expand the number of insured. Key elements actually originated with Republicans as they looked for alternatives to the single-payer path.

The past six years, Republicans have been so adamant in their opposition to the act that they have abandoned concepts they conceived and once backed. During the campaign, Donald Trump picked up another idea Republicans long have pushed. They want insurers to have the authority to sell policies across state lines.

That sounds reasonable. The thinking goes that consumers would enjoy expanded choices, the reduced administrative costs and accelerated competition resulting in lower prices.

The president-elect and other Republicans have suggested such a step would be part of the replacement.

What could go wrong? Health care analysts note that several states already permit out-of-state insurance sales. There is no current federal barrier. The Affordable Care Act even encourages sales across state lines.

The problem is, insurers have shown little interest. Analysts have explained that entering another state comes with a substantial burden, especially the work involved in establishing networks of doctors and hospitals to provide care. Then, there are the difficulties in navigating the demographics, an aging Ohio more costly than a healthier Washington or Utah.

So, selling health insurance across state lines hardly rates as an elixir. Which gets back to why the Affordable Care Act is the way it is, layered and complex, borrowing from markets yet providing an essential cushion to ensure fewer are left behind.

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