If Republicans had succeeded in ACA repeal in 2017: state snapshots

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Last week, David Anderson, Louise Norris and I looked at how many more Americans would be uninsured if the Republican effort in 2017 to "repeal and replace" the ACA's core programs had succeeded, as it very nearly did (90% of Republicans in Congress voted for the main House or Senate bills). 

"Repeal and replace" was a misnomer: the Republican bills would have established an inadequate replacement for the marketplace -- but simply ended the ACA Medicaid expansion, which has had more impact. According to CBO projections, the repeal bills would have reduced Medicaid enrollment by 8 to 9 by this year, and by 14-15 million as of 2024, when the phase-out of enhanced federal funding for the expansion population would be complete. With the expansion intact, Medicaid enrollment has increased by about 8 million during the pandemic. Enrollment by those specifically rendered eligible by the ACA has increased by about 20% since February.

We also prepared several state-specific versions, as frankly we were apparently caught in a pre-election op-ed tsunami and couldn't quickly place the original.  Below, I've pasted state-specific outtakes.

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Pennsylvania

In Pennsylvania, as the repeal bills were being voted on, 754,000 Medicaid enrollees owed their eligibility to ACA expansion criteria. All would likely have lost Medicaid coverage had repeal passed...

...in February 2020, just before the pandemic caused economic havoc, 12 million adult Medicaid enrollees were rendered eligible by the ACA, and 9.2 million enrollees in the ACA private plan marketplace received federal subsidies that paid for an average of 76% of their premiums. In Pennsylvania, 267,000 marketplace enrollees were subsidized as of February...

[Re Medicaid enrollment during the pandemic] 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. In Pennsylvania, enrollment increased by 178,000 from February through July. 

Michigan

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 – currently accessed by 96,000 Michiganders, while 212,000 receive federal premium subsidies that pay for an average of 76% of their premiums...

In Michigan, 800,000 current Medicaid enrollees owe their eligibility to ACA expansion criteria. All would likely have lost Medicaid coverage had repeal passed. Since the pandemic started triggering massive job loss, Medicaid enrollment enabled by the ACA expansion  has increased by 20 percent. None of the 130,000 “expansion” enrollees who have gained coverage in Michigan since this past February would have been eligible had the 2017 repeal effort succeeded.

Illinois

In Illinois, 273,000 marketplace enrollees were subsidized as of February 2020, while more than 631,000 current Medicaid enrollees owe their eligibility to ACA expansion criteria. More than 500,000 of them would likely have lost Medicaid coverage had repeal passed...

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, currently received by 118,000 enrollees in Illinois.

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Complete nullification of the ACA via the patently fraudulent Texas v. California suit, brought by 20 Republican attorneys general and governors  and now before the Supreme Court, is current Republican policy, urged by the Trump administration (at Trump's insistence). Success would increase the ranks of the uninsured by 23 million, according to an estimate by the Center for American Progress. Charles Gaba, who assisted in the analysis, has broken out projected losses by Congressional district.

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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? 

Republicans have already undercut ACA protections for people with pre-existing conditions

As Republicans who voted for last year's ACA repeal bills in the House and Senate profess now that they are committed to protecting insurance access for people with preexisting conditions, it's important to keep in mind a current fact of life that both complicates and clarifies what they tried to do in those bills and the harm those bills would have wrought.

It's this: Republicans have already adulterated the ACA's individual market protections for people with preexisting conditions by means comparable to those stipulated in the House bill, the American Health Care Act (AHCA), and in the Senate bill, the Better Care Reconciliation Act (BCRA).

The AHCA nominally retained the ACA's core protections -- guaranteed issue, modified community rating, and the Essential Health Benefits that each plan must provide. But once adorned with the MacArthur Amendment that made passage possible, the bill enabled states to obtain waivers that allowed insurers to medically underwrite policies offered to people who had experienced a gap in coverage. States could also write their own EHBs. Critics pointed out that once a medically underwritten market was established, healthy people would opt in, leaving the ACA-compliant market to the sick and so driving up premiums. Rewritten EHBs could make mincemeat of caps on yearly out-of-pocket spending, as those caps apply only to services covered by EHBs.