With the midterm elections just months away, the issue of health care is once again a topic of conversation in the halls of Congress, in boardrooms and at dinner tables across the country. To understand where the Affordable Care Act stands today and what consequences the November election may bring, ASU Now spoke with Swapna Reddy, clinical assistant professor in the College of Health Solutions.
Question: What happened to the Affordable Care Act (ACA)? Where does it currently stand?
Answer: Despite unsuccessful efforts by many members of the Republican majority in Congress and President Trump to repeal and replace the landmark legislation in 2017, the Affordable Care Act (sometimes referred to as "Obamacare") is still the law of the land. Around 8.8 million people signed up for 2018 coverage through Healthcare.gov, despite reductions to enrollment periods and a 90 percent cut to funding for dedicated advertising.
That being said, the ACA has had a few important setbacks, and their implications can be quite serious for those that depend on ACA-based coverage for their health care.
Q: Is the individual mandate gone?
A: A primary example is the current state of the ACA's individual mandate, which requires most Americans have a minimum level of health insurance coverage. Failure to do so resulted in a tax penalty, or fine. On Dec. 22, 2017, President Trump signed into law a sweeping tax bill, which included a provision eradicating the penalties for not having coverage; in essence, it removed the enforcement abilities of the individual mandate. There is a common misconception that this eradication went into effect at the signing of the bill; however, the individual mandate's tax penalty for noncompliance still stands in 2018 and will go into effect in 2019.
While the vast majority of Americans receive health coverage through their employer or a public health insurance program, those that do not have access or ability to pay for an employer's program and make too much to qualify for public programs like Medicaid have come to depend heavily on the ACA's individual insurance markets for coverage. A primary purpose of the individual mandate was to help stabilize insurance risk pools and markets so that not only (frequently) sick or high-utilizers of health care were covered, but also so the risk would be shared among healthier consumers as well. This would also have the effect of stabilizing premiums for all those covered through the markets.
Q: What can we expect to see happen this year with the marketplaces?
A: With the eradication of the individual mandate's tax penalty, it is likely that those sick and high-need individuals will remain in markets while healthier individuals will exit for cheaper plans. In doing so, markets will become destabilized and premiums will increase for those high-need individuals forced by necessity to remain.
Experts predict a general premium increase of 10 percent in the markets due to this change in the law. Many marketplace enrollees, almost three-quarters in Arizona, qualify for federal subsidies to help pay for premiums, which help to mute these spikes in cost. Nevertheless, fluctuations in policy at the federal level regarding subsidies threaten this safeguard as well, especially for the working poor.
This is also dangerous for the healthier individuals who choose to exit the marketplaces in favor of less expensive and bare-bones plans, especially in the event they develop a health issue that requires coverage that their plan does not provide, or provides at increased rates. Experts at the Congressional Budget Office predict that ultimately, repealing the individual mandate's penalty will result in 13 million fewer insured Americans by 2027, compared to the number of insured currently under the ACA.
Q: Where does Arizona’s health insurance marketplace stand?
A: Arizona's ACA marketplace was once among the most robust in the country. At the onset of 2017, many insurers fled the state's exchange, leaving many counties with only one insurance option. Resulting spikes in premiums made national headlines, though with the help of federal subsidies and what appears to be a financial correction, rates have stabilized. Nevertheless, Arizona witnessed a 15 percent decrease in enrollment on Healthcare.gov in 2018 compared to 2017.
Q: How might the November elections change the health care debate?
A: The midterm elections in November have the potential to have a tremendous impact on the fate of the ACA. There is a wide spectrum of approaches by candidates on how to address ACA-related challenges, such as high premiums. While it feels like a distinctly partisan issue, it is important to recognize that there are candidates from both parties that favor stabilizing the ACA — some in an effort to maintain and expand the reach of the legislation, and others in an attempt to stabilize premiums, especially for coverage that many in their constituencies have come to depend heavily upon. While there is still some talk of repeal and replace, that has become a less popular sentiment among candidates based on the legislative failures of 2017.
Increasingly, public support for repeal and replace is losing popularity. A recent poll by Kaiser Health found a slight increase in the share of the public who say they have a favorable view of the ACA, from 50 percent in January 2018 to 54 percent this month. This is the highest level of favorability of the ACA measured in more than 80 Kaiser Health Tracking Polls since 2010.
As is evidenced by outrage in town halls across the United States in 2017, Americans have become accustomed to and dependent on key ACA provisions, such as not being discriminated against for pre-existing conditions. Nevertheless, they remain fiercely pro-individual rights to make decisions about their health care and resistant to rising costs and premiums. As such, candidates on both sides will have to toe the line carefully on their ACA-related policy positions. With so much hanging in the balance and so many people's lives (literally) on the line, this election season is particularly relevant.
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