January 17, 2018

It’s 2018 – and the ACA is Still Popular

Illinios New 1 license plate for January 2018Last year we had what we hope will be the last significant legislative effort to repeal and replace the Affordable Care Act. The culmination came just a few days before Christmas with the signing of a bill undoing a major element of the ACA. It didn’t have any words like “healthcare” or “personal responsibility” in the title, but the Tax and Jobs Act, signed by President Trump on December 22, effectively eliminated the individual mandate as a spur for people to obtain coverage. The bill’s passage gave the majority their first legislative victory after nine years of efforts to kill the ACA. For those scoring at home, that puts the anti-ACA camp’s win-loss record at 1-70.

It was a victory that President Trump attempted to capitalize on, claiming soon after the signing that removing the individual mandate penalty meant that Obamacare is “essentially repealed.” The reality is much more complicated.

The individual mandate has not, in fact, been repealed. The language is still sitting in the law. All the tax bill did was change the penalty for being uninsured to $0 (HR. 1, Part VIII, Sec. 11081(a)(2)(A) of the bill). A future Congress could plug in a new number and BOOM! The mandate is restored.

We won’t know for some time the healthcare and health access impact of the penalty repeal. But the financial impact is already being felt. Companies that suffered a roller coaster ride in 2017 are now on solider ground. As a result, their financial outlook is improving. Since December 29, healthcare company stock prices have increased by 4%-5%.

Status of the ACA: very much not dead

It may seem like 2017 has been like one long remake of the “bring out your dead” scene from Monty Python and the Holy Grail where the peasant insists he’s not dead even though the man carrying him says he’s not fooling anyone and he’ll be stone dead any moment now. Like that peasant, the ACA is alive and kicking. Seven years and counting. How has it survived? There are lots of reasons, but here’s two:

It’s popular. The Kaiser Family Foundation has tracked public opinion about the ACA since 2011, and 2017 marks the first year where more than 50% of respondents had a favorable impression. And that’s despite all the efforts made last year to undermine and discredit it.

Core ACA protections are still in place. The biggest question facing the conservatives was: How would they kill the ACA when it had so many popular provisions? Turns out, they couldn’t. Coverage until age 26; pre-existing condition protection; essential health benefits; subsidies – they are all still there.

We are still facing fundamental challenges within our healthcare system, however. As a recent Vox explainer with Ezra Klein lays out, private spending on healthcare in the U.S. dwarfs that of other Western countries. We have fewer doctor visits per person than those countries, but we tend to pay more for the same procedures – and the prices at the same facility vary depending on who is footing the bill. Klein makes some interesting observations about what that means for future attempts to broaden access; it’s well worth your time to watch the whole five-minute video.

There are more issues on the horizon. CHIP reauthorization is up next: Monday, January 8, was 100 days since the program’s funding expired. Entitlement “reform” isn’t going away. We have yet to address the opioid crisis. Meanwhile, more active duty service members are coming home to face new challenges to healthcare access as they transition to civilian life.

Medicaid work requirements

As you’ve seen, states are being pushed to build more “personal responsibility” elements into their Medicaid programs. The hammer dropped Thursday when CMS clarified how and why it would support states in “helping beneficiaries improve well-being and achieve self-sufficiency.” The move has been expected: Even before her confirmation last March, CMS Director Seema Verma had made clear her intention to push Medicaid in this direction, as she was known for doing in Indiana under Mike Pence, and elsewhere. The CMS director has been quick to provide a rationale for this shift in Medicaid.

A number of states are accordingly writing proposals integrating work requirements. Some had submitted waivers in the past only to have CMS under the Obama Administration deny their application. The new administration is guiding this philosophical shift to becoming a reality in states, with Kentucky being the first. You can use KFF’s waiver tracker to follow the current status of waivers submitted or in process.

This developments is very troubling, especially for those in the disability community, who see the programs that foster disability employment being used as leverage to push people off Medicaid. CMS is walking a fine line by directing states to look at “able-bodied” Medicaid recipients while also acknowledging that many may actually have disabling conditions. This places pressure on states to determine the best form of employment supports for those beneficiaries that must meet a work requirement.

A recent analysis offers lessons learned from the experience of states that implemented work requirements for the Temporary Assistance for Needy Families program, the block grant prorgam that replaced Aid to Families with Dependent Children as part of 1996 welfare reform legislation. It is perhaps needless to say that not all the expected benefits were realized; but not long ago, we spelled it out.


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