If there’s one thing that Democrats and Republicans agree on, it’s this - virtually no one will tell you that the ACA is perfect. Once you get past that point, opinions on how to deal with that imperfection vary wildly.
At the heart of the ongoing federal government shutdown is what happens to tax credits to make the Affordable Care Act more affordable. Democrats want to extend them, while Republicans want to let them expire on December 31.
Those tax credits help a lot of people, as many as 24 million Americans according to KFF. But, they also come with a steep price tag - around $35 billion per year, says the Congressional Budget Office.
"That's really because health insurance is really expensive in the United States," said Cynthia Cox, Director of the Program on the ACA at KFF, speaking to PBS Newshour in late September. "So making it possible for lower income and middle income people to afford to pay for health insurance means that they'll need financial help to do so."
That presents a stark choice - tax credits or insurance premiums that could double or more. But, Delaware’s Insurance Commissioner, Trinidad Navarro, says that extending the tax credits won’t return things to the status quo.
That would be great," Navarro says. "However, that wouldn't have the significant impact that everyone thinks because the insurance companies have already had to file their rates."
Put another way, that means insurers have already determined, based on ACA credits expiring and a host of other factors - like morbidity and general trends - what their rates are going to be. And those other factors, like morbidity, are also impacted by the assumption that ACA credits are going away.
In addition to that, there’s another complication. As insurance rates rise, as they are likely to do, people begin making hard choices - insurance or rent, insurance or groceries, insurance or student loan payments. And for younger people in generally good health, insurance almost always loses.
"I don't know, and I cannot predict what it will be next year, but I imagine due to the cost of premiums that many younger, healthier folks just won't purchase it," Navarro says.
The problem with that is that young people get sick and injured too. And, Navarro says, forgoing preventative care now can cost a lot more later.
"You spend a little bit of resources early, but save them significantly - and save lives - because of early intervention on serious illnesses," he says.
As more people potentially drop health insurance, that causes a ripple effect - something the state saw less than a decade ago, Navarro notes.
"It's sort of a self-fulfilling prophecy in that less money's coming in, more money's going out, and it will lead potentially to companies leaving the state of Delaware," Navarro says. "This happened back in 2016 and '17 because insurers were losing so much money on the exchange."
Meanwhile, Navarro and his team are watching Congress carefully and trying to plan for an uncertain future.
"It's going to be a painful time," he says.
