Health Care Reform: ACA’s Likely Future Depends on Who’s Guessing

By Dana Beezley-Smith, Ph.D.
March 7, 2018 - Last updated: March 4, 2018

Affordable Care ActWhat’s the future of the Affordable Care Act? Among health policy wonks, answers vary – and largely align with one’s position on the law.

Referring to the conditions in the ACA exchanges, President Trump has long declared that “Obamacare is dead,” “gone” or “finished.”

The law remains on the books, of course, but Sally Pipes, president of the Pacific Research Institute and an ACA critic, believes the exchanges may soon collapse due to two recent threats. First, the administration ordered an expansion of short-term health policies, previously available only for 90-day periods. Such policies don’t have to conform to all the ACA’s regulations and are therefore more affordable.

The second blow Pipes sees is in last December’s Tax Cuts and Jobs Act, which repealed the penalty for not having health coverage in 2019 and beyond. The individual mandate has long represented the most unpopular feature of the statute.

The ACA currently fines those without coverage $695 per adult, $347.50 per child and up to the greater of $2,085 or 2.5 percent of household income. Pipes said, “This tax overwhelmingly falls on the working class. About 80 percent of the 6.5 million Americans who paid the penalty in 2016 earned less than $50,000 per year.”

“The availability of year-long term health plans and the absence of an individual mandate will prompt an exodus from the exchanges,” she contends.

Sen. Orrin Hatch (R-UT) also sees the individual mandate as essential to the law’s functioning. “Repealing the individual mandate tax is the beginning of the end of the ObamaCare era,” he wrote for Fox News.

But according to many in the journalist community, the ACA’s long-term prospects are resoundingly positive. Health policy reporter Dylan Scott, writing for Vox, left-leaning “explainer” website, says “the Affordable Care Act is going to survive. The 2010 health care law has slowly but surely moved out of the line of fire” and its “future is actually starting to feel secure.”

In a piece titled “Republicans Can’t Kill Obamacare,” US News and World Report reporter Susan Milligan calls the ACA a “zombie health care law.” Notwithstanding the efforts of those she calls “ACA haters,” the law “appears here to stay – and perhaps even flourish.”

Jeffrey Young of the Huffington Post writes that “Obamacare’s not dead,” citing as evidence the only slight dip in signups on the exchanges over the past two enrollment periods – “despite Trump’s sabotage campaign.”

By “sabotage,” Young is referring to policy changes such as halving the length of the Open Enrollment period and tightening up vetting for those applying under special circumstances. Outreach and marketing funds have been cut from $100,000 to $10,000, outlays for unlicensed assistance programs were dropped from $63,000 to $37,000 and $7 billion in unconstitutional payments to insurers were terminated. Even with these changes, 2018 enrollment decreased only 4 percent over the last signup period.

While there are deep divisions in how policy analysts view the law’s fate, on one point both sides seem to agree: In its current form, the exchanges are operating much differently than envisioned by the 2010 Congress.

Far fewer are enrolled than expected, mostly because employers haven’t yet dropped coverage for their workers. Eighty-three percent of enrollees receive taxpayer assistance for their expenses and many of the unsubsidized are canceling their coverage – plans that ACA architect Jonathan Gruber recently admitted “can be exorbitantly expensive.”

According to Mark Farrah Associates, a health care analysis firm, 29 percent of Americans in the unsubsidized market abandoned their policies last year. Individual market enrollment in 2017 declined by about 12 percent.

“The ACA is just a shrunken version of what it could be,” Gruber told The Hill. “It’s shrunk to a public entitlement program, and that’s, you know, unfortunate.”

A recent Gallup poll finds that the number of uninsured ticked up 1.3 percent in 2017, reflecting 3.2 million dropouts. Uninsured rates rose most among young adults, blacks, Hispanics and low-income Americans.

“By far, the biggest change in 2017 was the decline in the percentage of Americans purchasing their own plans,” reported the pollsters, who speculated that higher costs and confusion about the individual mandate were responsible for the change.

Policymakers’ opposition to the mandate penalty repeal involves concerns that even more Americans would forego coverage, as expensive patients dominate the exchanges and increase premiums. For enrollees who receive financial assistance, however, rising costs will be offset by proportional increases in federal subsidies.

The left-right battle over the statute’s provisions appears to be moving to the states. At least nine states are considering imposing an insurance mandate on their residents, and Idaho is proposing that plans be sold without ACA-mandated “Essential Health Benefits.”

“We should let states duke it out,” Andy Roth of the conservative Club for Growth believes. “If Maryland or Vermont wants to impose heavy regulation on health care, by all means let them do it.”

Kaiser Family Foundation’s senior vice president Larry Levitt takes comfort in that the law’s fundamentals remain untouched.

“The heart of the ACA has always been the Medicaid expansion, the premium subsidies to make insurance more affordable to lower-income people and the protections for preexisting conditions. Those things will all still be in place.”

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Dana Beezley-Smith, Ph.D., is in private practice serving children, adults and families in Green, Ohio. Her email is:

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