Every federal election held since Congress passed the Patient Protection and Affordable Care Act in 2010 has been a referendum of sorts on President Obama’s signature healthcare law. Perhaps Tuesday’s election will be the last one.
It certainly should be. The law better known as Obamacare laid a solid foundation for expanding health insurance coverage to more Americans, improving the quality of care and slowing the growth of healthcare spending. But rather than building on that foundation and tackling the tough work still to be done on cost control, Republican lawmakers focused all their efforts on futile attempts to wipe the law off the books.
In giving control of the House of Representatives back to Democrats for the first time since 2010, voters sent an unmistakable message in favor of the ACA. A centerpiece of many Democrats’ campaigns was preserving the protections the law provides to people with preexisting conditions. And according to exit polls, more than 40% of those surveyed said healthcare was their top issue — far higher than any other topic.
The GOP’s attempts over the last two years to repeal the ACA or change it to help younger, healthier Americans at the expense of those with preexisting conditions proved incredibly unpopular. And even the sharpest critics of Obamacare — including President Trump — reversed field in the campaign, pledging to keep insurance available and affordable to those with preexisting conditions.
Granted, keeping the ACA in place isn’t the only way to safeguard people with preexisting conditions who aren’t covered by large employers’ group plans. But doing so takes more than just a mandate that insurers not discriminate against such people or terminate coverage for those who get injured or sick. There also has to be some assurance that policies will cover all the services and treatments they need.
That latter piece is a key element of the ACA’s insurance reforms, and it’s been missing from the proposals advanced by congressional Republicans. The Trump administration, meanwhile, has sought to weaken that particular protection in several ways, most recently by inviting states to offer subsidized insurance plans that don’t cover all the ACA’s “essential benefits” — a move that would drive up premiums for people who need comprehensive policies.
Notably, the administration has pursued those changes even as the president was declaring how committed he was to protecting people with preexisting conditions. It’s a safe bet that Trump will continue trying to undermine the ACA despite the shift in Congress.
Yet the administration is swimming against the tide. Underscoring the growing support for the law, voters in three deeply red states — Idaho, Nebraska and Utah — on Tuesday approved proposals to expand Medicaid to more low-income residents, which was another important provision of the ACA. Once those changes go into effect, 36 states will have extended health coverage to households earning up to 138% of the federal poverty level (the previous limit had been 100%) and to poor but able-bodied adults without children.
Aside from the guerrilla warfare waged by the administration, the biggest remaining challenge to the ACA and the state insurance marketplaces (or “exchanges”) that it created may be the tax bill the GOP-controlled Congress passed in December, which will eliminate in 2019 the penalty for adult Americans who do not obtain insurance coverage. The bill gave opponents of the ACA an opening to challenge its constitutionality again, on the argument that the tax penalty had been the linchpin of the Supreme Court 2012 ruling upholding the law.
The lawsuit’s twisted logic should be its downfall. But ending the tax penalty will still weaken the state exchanges by removing an important incentive for younger, healthier Americans to sign up for coverage, a change that has raised premiums for 2019 an estimated 10% to 13%. Meanwhile, ever-rising treatment costs are driving up premiums for everyone with private insurance, as well as raising the bill for public insurance plans such as Medicaid.