With the failure to repeal/replace the Affordable Care Act (ACA) in Congress, state lawmakers should stop waiting on Washington to “do something” about health care. Congressional action, no matter what that action looks like, is unlikely to address the unmet Obamacare promises of delivering health-care access and affordability.

Furthermore, an upcoming decision from President Trump on what do about ACA’s cost-sharing reductions could make the future of the ACA even more chaotic. 

More uncertainty is looming
Cost-sharing subsidies totaling about $7 billion were implemented to reduce out-of-pocket costs, such as co-payments and deductibles, for individuals and families below 250 percent of poverty. The cost-reduction payments have not only been controversial, but they are also at the center of a legal battle. 

In 2014, House Republicans filed a lawsuit to end the payments since the funds were paid but never appropriated by Congress. The court sided with the House, but the Obama administration appealed. The Trump administration has yet to announce a decision on whether to continue these payments. 

These payments will not only impact potential premiums for the 2018 plan year, but also may determine whether there will be a continued exodus of insurers from the ACA exchanges. If these subsidies do not continue, exchange insurers may decide to exit the exchange markets. Their contracts with the U.S. Department of Health and Human Services (HHS) stipulate that, should subsidies end, they can immediately leave the market.

Insurers that stay are expected to raise their premiums even higher to cover the lost cost-sharing subsidies. That would be in addition to the already high anticipated premium increases.

Fewer insurers and higher premiums

Insurers have already been fleeing the exchange markets over the past couple of years. Last year, Pinal County, Arizona was in danger of being the only bare county in the U.S. The state Department of Insurance scrambled to bring in an insurer before open enrollment began.

For most counties, premium increases will be steep. Average premium increases will be in the neighborhood of 20 percent. Premium prices are coming due, and with the prospect of uncertainty looming well past that deadline, there is a good reason to believe that many markets will see rates rise even higher.

What states can do

Regardless of what happens next in Washington, state-level policymakers should continue to strive for meaningful health-care reforms to impact the cost of care in their states. Reforms such as expanding state scope-of-practice laws, rescinding certificate-of-need laws, and protecting charity care efforts can impact health-care access and cost of services.

Scope of practice: Health-care practitioners should be allowed to practice at the top of their education and training. For example, pharmacists are not allowed to administer vaccinations in some states despite being well qualified to do this with minimal risks to the patient. Furthermore, rolling back scope-of-practice laws can help alleviate the shortage of health-care providers, especially in rural areas.

Certificate of need: Facilities and services should be available on the basis of able and willing providers, not on government-sanctioned boards deciding who should be allowed to serve patients. Rather than restraining costs, certificate-of-need laws consistently restrict health-care access and competition.

Charity care: States can also enact Good Samaritan laws that provide legal protection for those offering health-care services. These protections can be particularly helpful for allowing charity groups to provide large-scale charity operations and for medical personnel wishing to assist in response to natural disasters.

Direct primary care (DPC): This is an innovative health-care arrangement that allows patients or their employers to contract with a provider for primary care medical services directly. DPC allows patients to directly and more immediately access non-emergency care and, under many arrangements, allows them to do so as many times as needed at no additional cost. Unlike a typical health-care arrangement, DPC operates independently of traditional health insurance. But in some states, decades-old regulations originally designed to govern the health-insurance market are being imposed on these arrangements, stifling the potential growth of this new health-care option.

Telemedicine: In many states, it is legal for doctors to prescribe treatments through the Internet without ever meeting a patient in person. Unfortunately, there is an increasing push in some states to impose new regulatory burdens on practitioners that have no significant bearing on patient safety. For example, some states have adopted distinct clinical practice rules for these new services that are more onerous than those imposed on traditional providers.

Promote access and affordability

While there is no silver bullet to the problems facing the American health-care system, the answer to the nation’s health-care woes doesn’t lie in bigger bureaucracies and less accountability. That is why state lawmakers should not wait on Washington. They should begin work on meeting the unmet goals of ACA, promoting health-care access and affordability.    

Naomi Lopez Bauman is Director of Healthcare Policy at the Goldwater Institute. The institute says its mission is to “defend and strengthen the freedom guaranteed to all Americans in the constitutions of the United States and all 50 states.”