I’ve thought about this a lot, and it’s difficult. There really is an awful lot I don’t like about the law so that my choice reflects more the "first thing" I'd like to change rather than the "one" thing I'd like to change. However, if I had to change one thing to benefit consumers, it would be to do away with the credits and rebates provided by the health exchanges based on percentage of poverty level. I’d get rid of them all.
First, the health exchange subsidies and rebates are only available to people earning between $11,490 and $45,960 a year, for an individual, and among those, only individuals who are not eligible for an employer plan.
Second, eligibility is based on adjusted gross income. If you own stock, the value of that stock would not be included so unless you pull dividends out of that stock, which would be counted, you could own stock and ALSO be eligible for the rebates and credits (see article by Michelle Andrews, 7/2/2013, “Income—Not Assets—Will Determine Subsidies in Online Insurance Marketplaces”).
To me, this means that small business owners, many of whom already underreport income (don’t flip out, it’s true) will have another avenue for their owners to take advantage of the exchanges while living in million dollar homes or having extensive stock portfolios.
This also means that stay-at-home moms whose husbands' insurance rates for dependents go through the roof, will be ineligible for the exchanges, ineligible for Medicaid, and therefore, will HAVE to be covered by the exoribitantly priced employer health insurance.
Third, health insurance and health care costs are going up, and I don’t believe that there is any likelihood that the PPACA will be responsible for ANY across the board reduction in these costs. While the Act attempts to institute means of saving money on Medicare, in accordance with usual cost-shifting you can count on insurers and healthcare providers using that as an excuse to raise rates on the non-Medicare population as well as using it as an excuse for less and worse care for the Medicare population.
Fourth, the credits and rebates are an artificial crutch designed to get buy-in for the exchanges. By helping people pay for premiums, the blow of what insurance premiums are and will be is softened. Much like the housing bubble, the artificial financing of health insurance through premium contribution sustains high premium pricing.
Remember the housing bubble? Financing of up to 100 percent artificially RAISED the prices of homes, and then people who could not afford the payments for their financed homes defaulted. Similarly, these Federal contributions will become a NECESSARY PERMANENT feature in order to sustain ever-increasing costs of insurance and health services or else, individuals who purchase healthcare working in the Federal contributions will be forced right back out of the insurance market.
Instead, I believe that without the rebates and credits, the number of uninsured would remain a stubborn reality, even with the individual mandate which provides for exemptions from the mandate for certain economic hardships.
Fifth, the illusory “more insured” number would better reflect the reality of how little the Affordable Care Act does without the use of rebates, credits and the penalty for non-insurance to get more people insured. Insurance costs chasing increasing health costs has not worked at all, and simply covering up that core problem with the use of credits, rebates and the individual mandate tax, will not solve that problem.
Sixth, the truly poor are completely omitted from health exchanges and in states where Medicaid expansion was rejected, these people’s lives are unaffected and unimproved by the PPACA.
Seventh, the PPACA is a ruse trying to soften what many of us know, as a country, instead of all the doubletalk, we should finally commit to the policy that we’re really supporting, if you’re rich you get health care and if you’re not, you don’t, unless you're part of a specially protected group. Perhaps then there could be a discussion of our nation's "values," without phony statistics and justifications for horrendous policy.
Modification of the PPACA requires a reality check, and the artificial use of rebates and credits to disguise the inability of our society to commit to lowering the costs of health insurance by lowering the costs of medical care is NOT helped by the PPACA.
