Now Texas Sen. Ted Cruz, a Republican, wants to again allow insurers to sell whatever bare bones coverage they desire and consumers to purchase it. To qualify, insurers would just have to offer one plan that complies with the ACA's comprehensive benefits standard.
It may sound good in theory — free markets and freedom of choice — and it's an idea that has long been popular with conservatives. But experts say insurance simply doesn't work this way, and the "Cruz amendment" would unleash destructive forces for individuals without employer-sponsored coverage as well as for the system.
The senator and his allies "have been very clear," said Sarah Lueck, a senior policy analyst for the Center on Budget and Policy Priorities, a left-leaning think tank. "They want lower premiums, and they think that keeping healthy people and sick people separate keeps premiums lower. Well, it does. For healthy people."
But, she added, "From an insurance perspective, and from a consumer protection perspective, it wouldn't work."
The insurance industry echoed that late Friday, strongly opposing Cruz's "Consumer Freedom Option" in a letter to Senate Majority Leader Mitch McConnell, R-Ky., and Minority Leader Charles Schumer, D-N.Y.
"It is unworkable in any form and would undermine protections for those with significant medical conditions, increase premiums and could lead to widespread loss of coverage for people currently enrolled in the individual market," wrote the main industry trade group, America's Health Insurance Plans, and the Blue Cross Blue Shield Association.
Ultimately, the starkly explicit letter warned, "This provision will lead to far fewer, if any, coverage options for consumers who purchase their plan in the individual market. As a result, millions of more individuals will become uninsured."
Here's how this all would play out: Insurance premiums paid by the vast majority of healthy people, who use relatively few medical services each year, cover the costs for those who are ill and require the care provided by the world's most expensive health system. Leaving aside myriad complexities of insurance markets, ideally it balances out. People are covered for much of the care they get, insurance companies make a profit, and health care providers are reimbursed for their services.
Yet if the sick and the well are sorted — or sort themselves — into separate pools, the system can start to fall apart. With the well no longer subsidizing the sick, the latter may face ever-escalating premiums or fewer choices entirely if insurers no longer are required to sell to anyone who wants to buy a policy.
And in a related scenario, people who are priced out the market because of a pre-existing medical condition, who turn to a health plan with minimal coverage, can find themselves unexpectedly facing very high bills. So can individuals on such a plan who are diagnosed with a serious disease like cancer.
Meanwhile, everyone else who receives insurance through the workplace or can afford to purchase robust coverage continues in a de facto separate system.
"It's just Insurance 101," Lueck said. "You don't create two disparate markets and then let healthy people leave your marketplace."
Under the Senate bill, the ACA's premium subsidies would still be available to those earning up to 350 percent of the federal poverty level, blunting the cost for many. But middle-income Americans who earn more could face skyrocketing costs without the same consumer protections afforded under the 2010 health-care law.
Those Americans would still be subject to a penalty if they didn't maintain continuous coverage. The Senate legislation erases the ACA's individual mandate to buy coverage, replacing it with a six-month waiting period for those who have been uninsured for at least two months in the previous year.