The Future of the Affordable Care Act

Meg Barbor, MPH

August 2017, Vol 7, No 8 - Health Policy


Washington, DC—Movement on the American Health Care Act may continue, and the evolution of the Affordable Care Act (ACA) is not known, said Elizabeth Carpenter, Senior Vice President, Avalere Health, at the 2017 Association of Community Cancer Centers meeting.

Congress and the administration are considering a range of actions on the ACA. The ACA granted flexibility to the secretary and agencies of the Department of Health & Human Services (HHS) in implementing the core aspects of the plan, even if the ACA is not repealed.

“In the same way the Obama administration used those flexibilities to advance their priorities, the Trump administration will have the flexibility to use that regulatory authority to make policy changes as to how the law is implemented,” said Ms Carpenter.

The Trump administration will grant additional flexibility to states in administering their Medicaid programs, potentially allowing for increased financial responsibility on behalf of beneficiaries, implementation of work requirements, or blackout periods. In addition, continued litigation over cost-sharing reduction subsidies means that approximately 50% of individuals on the exchange are at risk for losing those reductions, said Ms Carpenter.

The 2018 Plan Year Is Upon Us

Currently, approximately 1 in 3 US regions has only 1 participating health insurance issuer on the exchange, and additional issuers are considering exiting the market. Humana recently announced its decision to exit the market in 2018, potentially leaving 16 counties in Tennessee without insurance options, unless another carrier enters the market.

“The reality is, while all of this is going on around us, real consumers are looking ahead to the 2018 plan year. And a lot is going to happen in the next 6 months,” she said.

In June or July, the Independent Payment Advisory Board (IPAB) trigger determination will be announced. IPAB is the entity designed to keep Medicare spending in check under the ACA, and is designed to bring per-capita Medicare spending back in line with statutory benchmarks, if those benchmarks are exceeded.

“In the absence of an IPAB board, the authority to make recommendations for cuts to Medicare will transfer to the secretary of HHS, giving the Trump administration a vehicle to advance particular policies with limited Congressional involvement,” she said.

These legislative milestones will transpire at the same time insurers are making decisions regarding their involvement in the market. “There are a lot of opportunities for Congress to continue to debate aspects of the ACA, if not repeal and replace more broadly,” said Ms Carpenter. “Advocates, patients, and stakeholders should continue to be mindful of that reality.”

Potential Impact on Low-Income Patients

By the end of 2015, an estimated 28.5 million nonelderly Americans were uninsured, a decrease of nearly 13 million since 2013. This reduction was primarily a result of Medicaid expansion and the establishment of the Health Insurance Marketplaces under the ACA, said Alan Balch, PhD, Chief Executive Officer, Patient Advocate Foundation.

“It’s important to remember that prior to the ACA, people still got care, but that system of charity care has largely been dismantled now,” he said. “I think that’s part of the problem with going back to the world as it was before the ACA. The means people had to navigate the system are, in large part, gone, and it would be hard to recreate that,” added Dr Balch.

People tend to choose their healthcare based on their monthly premiums, but this does not mean they do not want robust coverage, he said. Certain basic principles should be applied to the provision of healthcare: insurance benefits must continue to provide adequate coverage for all patients; and patients facing severe health issues or preexisting conditions should have adequate coverage and access to care.

Health insurance plans must be transparent so that consumers can make informed decisions on their coverage, and insurance companies should provide access to a transparent and easy-to-navigate appeals process.

“The problem with healthcare is that it’s all interconnected,” said Dr Balch. “You can’t fix one thing without breaking another, and that’s part of the inherent problem. There’s no magic bullet.”

To provide meaningful and broad coverage, insurers should also avoid changes or restrictions that are likely to create discriminatory outcomes for disadvantaged patients fighting chronic or life-­threatening illnesses.

“Low-income patients need a premium discount and out-of-pocket subsidies to be able to afford health insurance in the first place,” Dr Balch said. “So if you don’t subsidize coverage at some level for low-income patients, many of whom are likely to get chronic diseases, you’re not really providing them with a way to get coverage.”

Premium penalties for those who do not maintain continuous coverage would also disproportionately affect low-income patients. This would likely create a significant financial hurdle and could prevent them from being able to find their way back into the market, said Dr Balch.

Joining Forces for Change

Healthcare is expensive, out-of-pocket costs are increasing, and premiums have risen every year since 2001. “Broad, comprehensive healthcare reform is difficult to achieve, even when one party controls all 3 branches of government, and the first attempt under Trump didn’t work so well,” Dr Balch said. “But having a big Christmas tree bill around healthcare reform is probably not in the cards. I think the key will be identifying a couple of key priorities and putting forth proposals to address those.”

Conversations around “repeal and replace” often turn political rather than maintaining a focus on policy change. “I hope we’re past repeal and replace. I hope we can instead amend it and fix it within the construct of the ACA,” he said.

If stakeholders, patient groups, insurers, employers, providers, and professional societies came together to find a specific set of solutions, they could lead the proverbial horse to water. “If Congress and the agencies know we’re all on the same page, it’s much more likely that we can come to some consensus and put the onus on the legislative community to follow our lead. That’s probably more likely than expecting the Democrats and Republicans to come together on an issue that’s been so divisive for so many years,” concluded Dr Balch.