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On the Third Hand: PPACA 2.0

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Whether you love the Patient Protection and Affordable Care Act (PPACA) provisions that affect the commercial health insurance market or hate them, the law affects the insurance ordinary people use to pay for checkups and heart transplants.

The U.S. Supreme Court refused to kill PPACA in 2012, and the court refused a second chance to kill PPACA this summer.

See also: King v. Burwell decision a relief for HR managers

In the days before the court ruled on King v. Burwell, even many congressional Republicans had trouble coming up with a PPACA alternative. Some worried about the consequences of killing PPACA without providing an alternative.

See also: What some conservatives aren’t willing to do to kill PPACA

I think the lesson is that opponents of PPACA should separate the idea of trying to kill PPACA from the idea of making genuine bipartisan efforts to improve the law. Health insurance is too important to try to let it operate as poorly as possible just to make the Democrats look bad.

Similarly, supporters of PPACA should stop repeating talking points, over and over, that boil down to, “PPACA is nice. It helps people,” and get serious about improving how PPACA World works.

Here are some ideas about where to start:

1. Make the U.S. Department of Health and Human Services (HHS) comply with serious reporting and operational transparency requirements.

The exchange system has been up and running since January 2014, but HHS still hasn’t made any effort to give us clear, complete data on any aspect of PPACA compliance or any part of the PPACA exchange system.

We have a little data on exchange plan selection numbers, the uninsured rate and minimum medical loss ratio rebates. Beyond that, lies monsters.

2. Consolidate the state-based exchange system.

States like California, Colorado and Connecticut seem to have exchanges that operate reasonably well, with a reasonably high level of transparency.

Agents and brokers in those states have frightening stories about how terrible the glitches can be even in “the states with the good exchanges,” but those exchanges’ relatively high level of transparency suggests that those exchanges have the capacity to improve.

Some of the other surviving state-based exchanges provide so little disclosure that it’s not clear how they’re really doing.

It’s time to kill off the weak, secretive state-based exchanges and put their operations under the jurisdiction of state-based exchanges that know how to stream board meeting videos on the Web.

3. Phase out the exchange system’s monopoly on access to PPACA premium tax credits and cost-sharing reduction subsidies.

HHS already lets insurers offer tax credits through brokers, or through direct sales, whenever offering the credits through exchange enrollment systems is hard.

And it seems, from U.S. Government Accountability Office (GAO) reports and Treasury Inspector General for Tax Administration (TIGTA) reports as if the exchange system has no magical data security powers.

PPACA opponents’ exchange security demands may be unrealistic. Who knows how good Medicaid data security or Medicare security data security really was before 2010? Probably not all that great. But it doesn’t look as if the exchange system is any more secure than any other U.S. commercial product distribution system. Agents and brokers who are allowed to connect with the IRS personal data verification hub could probably protect applicants’ data about as well as the public exchange programs.

Assuming that’s the case, the only reasons to give the exchange system a unique ability to offer subsidies are to maximize public exchange system traffic, and to stomp on agents and brokers.

On the one hand, agents and brokers need to earn a living. Keeping in the U.S. health finance system has a monetary cost.

On the other hand, trying to replace agents and brokers by having public exchanges programs’ computer do what agents and brokers do has a monetary cost, too, and doesn’t seem to work very well.

On the third hand, the members of Congress who could read this column probably won’t have to look at it, anyway, because they’re too busy dealing with the consequences of international hackers hacking into their health insurance data…

See also: Hackers breach D.C. insurer in latest attack on a health company