What 'repeal and replace' really means for healthcare coverage
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A question that quickly arises during discussions of repealing and replacing the Affordable Care Act (ACA) is the impact on the number of individuals covered by insurance in the ACA’s individual marketplaces. As a matter of logical necessity, however, one must first decide what coverage will look like under current law.

One answer to this question is to simply look at the Congressional Budget Office (CBO) baseline projections that anticipate coverage of 10 million individuals in 2017, and a sharp rise of 30 percent over the following three years to stabilize at 13 million individuals. The CBO itself, however, has given cause to take that optimistic scenario with a large grain of salt.


Successive CBO projections for the next several years show the steady deterioration of marketplace coverage. For 2018, the original projection anticipated 27 million individuals. Now, CBO expects 11 million, well less than half of that number. Indeed, even just last year CBO was pegging coverage at 18 million. The pace of deterioration is such that the number was cut by nearly 40 percent in a year.


Weirdly, despite this steady down spiral, the current CBO projections anticipate coverage that rises by 30 percent over the next 10 years and plateaus at 13 million. Looked at slightly differently, CBO expects the fraction of the population between ages 25 and 64 covered by the marketplaces to jump from under 6 percent to nearly 7.5 percent. Granted, that is less than one half of the fraction in its rosy original projections, but still somewhat startling.

An explanation may lie in the assumption that coverage is determined by “demand” or the number of people who choose to enroll. This ignores the collapsing supply side of the ACA marketplaces as insurers head for the exits. Five states and fully one-third of all counties now have only a single insurer, and it is easy to anticipate the development of areas with no insurers, a corresponding zero for the number covered, and the need, yet again, for CBO to move its projections toward reality.

Outside experts have come to a different conclusion. The nonpartisan Center for Health and the Economy sees enrollment falling from 10 million to 7 million — just 4 percent of the prime-age population — over the next 10 years. This is one reason its analysis of the House “A Better Way” plan showed an increase in the number of individuals covered by insurance in the individual market.

There will be a serious debate about the cost control, choice, and coverage characteristics of any plan to replace the ACA. But the discussion should begin with a realistic assessment of the outlook for the status quo.

Douglas Holtz-Eakin is president of the American Action Forum. He also serves on the board of the Center for Health and the Economy. He served as director of the Congressional Budget Office during the George W. Bush administration.

The views expressed by contributors are their own and are not the views of The Hill.