Friday, October 30, 2020

What if Republicans had succeeded in repeal of the Affordable Care Act?

I've teamed up with friends for this final pre-election reminder of what the Republican healthcare agenda is really all about.

By Andrew Sprung, David Anderson and Louise Norris

On November 10, the Trump administration will ask the Supreme Court in oral argument to declare the Affordable Care Act unconstitutional – and nullify the law in the midst of a pandemic, uninsuring an estimated 23 million people. As Republicans rushed to confirm the nomination of Amy Coney Barrett to the Supreme Court, Senate Majority Leader Mitch McConnell  asserted that “no one believes” the Court will strike down the law – implying, as many hard-pressed Republican incumbents have also implied, that Republicans have no wish to do so.

But ACA repeal has been Republican policy since President Obama signed the bill into law in March 2010.  In 2017, a Republican House and Congress came within a whisker of repealing the ACA’s core programs, and 90% of Republicans in Congress voted for repeal. Where would be now if they had succeeded? How many more Americans would be uninsured, and what options would be available to the millions who have lost job-based coverage since the pandemic reached our shores? 

Republican "health reform": Cut ACA subsidies and Medicaid

In May 2017, the Republican House passed the American Health Care Act (AHCA). The nonpartisan Congressional Budget Office (CBO) forecast that if the bill passed,19 million fewer Americans would be insured by 2020 and 23 million by 2024. CBO projected similar coverage losses for the Better Care Reconciliation Act (BCRA), the companion Senate bill.  After nine Republican senators defected to help defeat passage of the BCRA, a “skinny” repeal bill that would have opened the door to passage of a revised House bill failed by a single vote when John McCain unexpectedly turned his thumb down.  

Both the AHCA and the BCRA would have sharply reduced the ACA's premium subsidies in the individual market for health insurance and would have rendered the available coverage virtually unusable for millions of low-income enrollees by eliminating the ACA's Cost Sharing Reduction subsidies. But both bills did their deepest damage by eliminating federal funding for the ACA Medicaid expansion, which extends Medicaid eligibility to all adult citizens and some legally present noncitizens with incomes up to 138 percent of the Federal Poverty Level (this year, that's $1,467 per month for an individual). CBO forecast that under both bills, expansion enrollment would be wiped out, reducing Medicaid enrollment to 8 to 9 million by this year, and by 14 to 15 million as of 2024.

Both bills would also have fundamentally altered Medicaid by converting federal funding to a capped contribution that would grow more slowly than medical inflation.  Under such per capita caps or block grants, states would now be bearing all pandemic and recession cost risk even as state revenues have collapsed.   

The nonpartisan Center for a Responsible Federal Budget estimated that the BCRA would reduce Medicaid spending by more than $2 trillion over 20 years, progressively weakening coverage for tens of millions who were not disqualified by repeal of the ACA expansion.

After their failed repeal efforts, Republicans chipped away at the margins of the ACA's core programs: the subsidized private plan marketplace and the Medicaid expansion. According to the federal National Health Interview Survey, the national uninsured rate  has increased from an all-time low of 9.0% in 2017 to 10.3% in 2019.  Still, in February 2020, just before the pandemic caused economic havoc, 12 million adult Medicaid enrollees were rendered eligible by ACA expansion criteria, and 9.2 million enrollees in the ACA private plan marketplace received federal subsidies that paid for an average of 76% of their premiums. 

45 Million uninsured -- and climbing

Had either Republican "repeal and replace" bill been enacted in 2017, the uninsured population by February 2020 would almost surely have risen to about 45 million, as projected by CBO – about 50 percent higher than its actual level. The pandemic would doubtless have accelerated the climb to 49-50 million uninsured that CBO projected by 2024.

Instead, when the pandemic struck and triggered tens of millions of job losses, the ACA's core programs stood as a gap-ridden but still substantial defense against massive increases in the uninsured population. The yeoman's work has been done by the Medicaid expansion.  Medicaid eligibility is determined by current monthly income, so that someone who loses a middle class job during the pandemic may immediately qualify. 

By June, according to the Center for Medicare and Medicaid Services, Medicaid enrollment had grown to 75 million — an increase of 4 million since February. Enrollment growth has continued throughout this pandemic. It is likely now stands at 78 million, about 10 percent above the February total. Among those rendered eligible by the ACA Medicaid expansion, enrollment growth is in the neighborhood of 20%. At least 14 million current Medicaid enrollees would be ineligible in a “Repeal and Replace” world.

The ACA marketplace offers more limited protection -- due to both the administrative burden of verifying enrollment eligibility and the determination of subsidies by annual instead of monthly income. Still, by one estimate, marketplace enrollment is likely about 1 million higher than it would have been absent the pandemic. Regulators have prepared the marketplaces for significant new enrollment during the fall open enrollment period. 

The uninsured population has doubtless increased during the months of unprecedented job loss triggered by the pandemic. But it would have risen faster and farther -- and from a much higher base -- had the Medicaid expansion and the current ACA marketplace been eradicated.

Even with the likely accession to the Supreme Court of Trump nominee Amy Coney Barrett, who has opined that the Supreme Court wrongly declared the law constitutional in 2012, McConnell may right in predicting  that the Court will not void the entire law. But that is what the Trump administration and the 18 Republican attorneys general and governors prosecuting the suit are asking for. ACA nullification has to be regarded as the policy of a party that at its national convention declined to produce any platform other than a statement of fealty to Trump.

David Anderson, MSPPM, is a research associate at Duke University’s Margolis Center for Health Policy. He blogs about health insurance markets at Balloon Juice

Louise Norris is an individual health insurance broker who writes about health insurance and health reform at and other publications

Andrew me

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  1. Thanks, the three of you, for highlighting what the Republicans have proposed, and want. It would indeed be a terrible step backwards.

    Of course, when we throw in the President himself, the issue becomes even more miserable, as we suspect the President himself doesn't understand what the Republicans have proposed in the past, and what is possible to engineer. (Paul Krugman pointed out both of these complications in recent columns. On the "what is possible to engineer", he has nicely put it that you can't get anything good enough without having something very much like the ACA, or, something to the left, like Canada Single Payer, or U.K. NHS.)

    I note the latest from the President's team, representing the President being some combination of a liar and in la-la land, has the latest administration status on PBS Newshour from a few days ago: at 25:15 to 28:30,

    Brooke Rollins, the "Acting Director of Trump's Domestic Policy Council" tells Judy Woodruff that the forever-forthcoming Trump health plan to replace the ACA actually already came out, this past Sept. 24, and is on the White House Website:

    Interviewer Woodruff, without the page in hand, said "I meant an actual plan--a bill submitted to Congress".

    The 'plan", an "executive order", if you read it, is not much, perhaps nothing.

    It, in fact, concludes with:

    " 6(c) This order is not intended to, and does not, create any right or benefit, substantive or procedural, enforceable at law or in equity by any party against the United States, its departments, agencies, or entities, its officers, employees, or agents, or any other person."


    As you know from prior posts of mine here, the ACA has a lot of problems in its current state. They are mostly fixable. Biden has proposed some fixes which do get at much of the affordability problem.

    (Other problems are not fixed, like the Medicaid estate recovery in 10-14 states on expanded Medicaid and other Medicaids for people 55 and over. As well, I've noted that apparently some states, like my own MA, are messing up coordination of the various parts of the ACA --expanded Medicaid and on-exchange, etc., due to the complicatedness of the law and causing coverage gaps. I know this because it happened to me about five times.)

    Unfortunately, a simpler and better solution, Single Payer, appears politically impossible for a good while, so the best we seem to be able to hope for is holding the ACA and fixing it as much as possible. (If we even get a sufficient Democratic Senate majority to repair the ACA.)

    (The country is fundamentally pathetic on health insurance. I guess the only question is exactly how pathetic. I appreciate you all working to try and keep us less pathetic.)

  2. Since we have three health policy experts on this blog post instead of the usual one, let me insert a fun quiz.

    Q. Supposing a state has expanded Medicaid, but hasn't figured out to harmonize expanded Medicaid income periods with the ACA by making expanded Medicaid income annual, like the ACA, and instead keeps monthly.

    Construct an example of where a person of annual income very low (say under 200% FPL) can get neither expanded Medicaid nor subsidized on-exchange certain months?


    Solution. To present the solution more easily (it makes no difference), I will oversimplify, and ignore that ACA income is "following year (estimated)" and assume it is same year.

    Alternate monthly income 30% OF FPL and 150% of FPL each month of the year.

    During the six 150% of FPL months, the person doesn't get expanded Medicaid (since income is over 138% FPL that MONTH), and doesn't get subsidized on exchange, since annual income is only 90% of FPL (rather than the 100% needed for on-exchange subsidies.)

    (When the ACA was passed, it was obvious to me that this problem would exist if states had expanded Medicaid eligibility monthly. I believe I saw two statements of this problem by experts on the web at the time, though I can't find them on the web now.)

    Anyway, I've myself had substantial problems in MA with the agencies giving me coverage gaps as they re-estimate my incomes whichever way they wish. I haven't had gaps emanating from this particular issue, but it does look to me from the questions MA asks on its ACA application site that it has held Medicaid eligibility as monthly, and the problem must exist.)

    (It's just one of the many defects of our country's insisting on, at best, a Rube Goldberg contraption for health care.)

  3. 1. Amy Barrett has gone on record only to say that the individual mandate may be unconstitutional now. She has not gone on record to say that the entire law should be voided.

    In fact, she recently participated in a moot court where all eight judges agreed that the overall law should stand.

    The whole episode is baffling to me in some ways. Trump only cares about discrediting Obama. The Republican conservatives are just bomb-throwers, they want chaos.

    What is driving the 18 state attorneys general who joined this flimsy lawsuit? Comments welcome.