The Affordable Care Act (ACA) had a roller-coaster of a year. It began with threats of almost certain repeal, followed by effort after unsuccessful effort to dismantle it. Then in the last days of 2017, there was the successful repeal of the individual mandate and penalty.
This was brazen politics, suspenseful and often agonizing.
It was a year when a senator’s dramatic thumbs-down meant survival of the law, drawing audible gasps in Congress. It was also a year when a very unpopular tax-cut bill (one that actually had less support than past tax hikes!) managed to draw first blood in the ACA battle.
As we look to 2018, it might be tempting to concede that this first wound could be fatal. President Trump has already declared that eliminating the penalty “essentially repeals Obamacare“. But I’m not all that convinced.
Here are three reasons why I think the pro-ACA resistance should take heart and could be poised to succeed this coming year:
1. Enrollment in ACA plans is strong
Despite cuts to outreach budgets and a shorter enrollment period, early indications are that people are continuing to enroll in ACA plans at rates similar to the prior year. Reports from The Hill and CMS suggest that healthcare.gov usage had been higher than usual during the earliest weeks, and that enrollment had reached almost 9 million (similar to earlier years). That number doesn’t include the states that have their own marketplaces. California, which has the nation’s largest marketplace, is reporting early numbers that are about 10% higher than the prior year (1.4 million). The total enrollment was almost 13 million nationally in 2016.
2. The most unpopular part of the ACA is now gone
The individual mandate and its penalty have always been the most hated part of the ACA. More accurately, as Andy Slavitt (the former acting administrator for CMS under President Obama) put it, it has been the only provision that didn’t enjoy widespread support. The other provisions–including protection for people with pre-existing conditions, allowing people under age 27 to be covered under their parents’ policies, and providing subsidies to help families afford coverage–have been tremendously popular. With the mandate gone, support for the ACA may grow, making further efforts at repeal less likely or less successful.
3. Insurance rates will remain unaffected for most people
Health care reform relies on bringing healthy people into the individual market to bring down insurance rates. The individual mandate, as despised as it was, was a final nudge (after the allure of protection granted by insurance and the pocketbook lure of subsidies) to help bring those healthy people into the market. With the penalty for non-coverage removed, we can expect some healthy people in the exchanges to drop their coverage (the CBO predicts about 4 million people in 2019). This will drive up health insurance rates on the exchanges by about 10%. But since subsidies are tied to cost of the plans, they will offset most of the rate increases. People who receive subsidies (which is about 75% of all marketplace enrollees) probably won’t feel the sting. The federal government, however, will.
The ACA, for now, remains the most practical way forward
Overall, the public resistance to repealing the ACA has been stalwart. It is powered by local action, with passionate supporters repeatedly flooding town hall meetings and convincing legislators. Because of this type of resistance, even the tax bill passed by a relatively narrow margin, and because of this, the political outlook for 2018 suggests that ACA repeal is not at the forefront of the Republican agenda.
Many supporters of the ACA, if presented with the opportunity, might prefer to push forward to a single-payer style health care system. But for the next few years, the current law remains the most practical way forward.
Those who have been following the battle over the ACA since it began know that, despite the political hype, it represents a moderate approach to helping more people get health insurance. It has helped millions of middle-class families get private health insurance and millions more lower-income families get Medicaid.
It brought the uninsured rate down to its lowest point in history, and it did so by embracing health care markets (a conservative cornerstone) and providing government support to help people with limited means (a liberal approach) use those markets. If there was ever a health care reform bill designed to bring Republicans and Democrats within a handshake’s distance, it was probably this one. Until it wasn’t.
Few probably remember that President Obama led 6+ hours of bipartisan roundtables on health care reform. Those publicly televised sessions brought together major health care stakeholders for surprisingly sincere conversations. Rather than opponents drawing lines in the sand, we saw remarkable displays of flexibility to fix a system few were happy with.
The law eventually included measures that were objectionable to some (i.e., a requirement to buy insurance or pay a penalty, a requirement that all states expand Medicaid, and rules that employers must offer family planning coverage despite religious objections). It’s not so surprising that these became the focus of major Supreme Court cases.
As 2018 approaches, the ACA finds itself substantially altered by years of efforts to challenge and dismantle it. These changes are not its demise, but arguably more of a re-balancing. There are pressing challenges ahead to stabilize markets, assure adequate choice of insurance plans in every community, and keep the core goals of a social program in a conservative era. The pro-ACA resistance should be emboldened to fight.