By Andrew Sprung, David Anderson and Louise Norris
On November 10, the Trump administration will ask the Supreme Court in an oral case to declare the Affordable Care Act unconstitutional – and repeal the law in the midst of a pandemic, uninsured 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 claimed that "no one believes" that the court will repeal the law – suggesting, as many hard-pressed Republican envoys have also indicated, that Republicans have no desire to do it.
But the ACA's repeal has been Republican policy since President Obama signed the bill in March 201
Republican “Health Reform”: Reduce ACA Subsidies and Medicaid
In May 2017, the Republican House approved the American Health Care Act (AHCA). The Non-Partisan Congressional Budget Office (CBO) predicted that if the bill passed, 19 million fewer Americans would be insured by 2020 and 23 million by 2024. The CBO calculated similar coverage losses for the Better Care Reconciliation Act (BCRA), the accompanying Senate bill. After nine Republican senators stepped in to help defeat the BCRA's failure, a "lean" repeal bill that would have opened the door for passage of a revised House bill by a single vote failed when John McCain unexpectedly twisted his thumb.
Both AHCA and BCRA would have significantly reduced ACA's premiums in the individual health insurance market and would have made the available coverage virtually unusable for millions of low-income earners by eliminating ACA's cost-sharing subsidies. But both bills did their deepest damage by eliminating federal funding for the ACA Medicaid expansion, which extends Medicaid's eligibility to all adult citizens and some legally present non-citizens with incomes up to 138 percent of the federal poverty line (this year it is $ 1 467 per month for an individual). The CBO predicted that under both bills, the expansion registration would be wiped out, reducing Medicaid's registration to 8 to 9 million this year and by 14 to 15 million from 2024.
Both bills would also have fundamentally changed Medicaid by converting federal funding to a limited contribution that would grow more slowly than medical inflation. Under such per capita ceilings or block grants, states would now have all the risk of a pandemic and recession even when state revenues have collapsed.
The Non-Partisan Center for a Responsible Federal Budget estimated that BCRA would reduce Medicaid's spending by more than $ 2 trillion over 20 years, gradually weakening coverage for tens of millions who were not disqualified by repealing the ACA expansion.
Their failed repeal strained Republicans on the fringes of the ACA's core program: the subsidized private plan market and the Medicaid expansion. According to the Federal National Health Survey, the national uninsured interest rate has risen from a low of 9.0% in 2017 to 10.3% in 2019. Still, in February 2020, just before the pandemic caused economic chaos, 12 million adult Medicaid Notifications were justified under the ACA Enlargement Criteria and 9.2 million registered entrants to the ACA's private plan market received federal subsidies that paid for an average of 76% of their premiums.
45 million uninsured – and climbing
If either the Republicans' "repeal and replacement" law had been passed in 2017, the uninsured population would have risen to about 45 million by February 2020, as calculated by the CBO – about 50 percent higher than the actual level. The pandemic would undoubtedly have accelerated the rise to 49-50 million uninsured as the CBO expected in 2024.
Instead, when the pandemic struck and triggered tens of millions of job losses, the ACA's core program stood as a cleft but still significant defense against massive increases in the uninsured population. Jeoman's work has been carried out by the Medicaid expansion. Eligibility for Medicaid is determined by current monthly income, so that someone who loses a middle-class job during the pandemic can immediately qualify.
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. Registration growth has continued throughout this pandemic. It is probably now at 78 million, about 10 percent over the February sum. Among those made eligible for the ACA Medicaid expansion, growth in the immediate area is 20%. At least 14 million current Medicaid applicants would not be eligible for a "Cancel and Replace" world.
The ACA market offers more limited protection – due to both the administrative burden of verifying eligibility and the determination of annual instead of monthly income subsidies. According to an estimate, market entry is probably about 1 million higher than it would have been in the absence of the pandemic. Regulatory authorities have prepared the marketplaces for significant new notifications during the open open notification period.
The uninsured population has undoubtedly increased during the months of unparalleled job loss triggered by the pandemic. But it would have risen faster and longer – and from a much higher base – if Medicaid expansion and the current ACA market had been eradicated.
Even with the probable affiliation with Trump nominee Amy Coney Barrett, who has argued that the Supreme Court wrongly declared the law constitutional in 2012, McConnell may be right in predicting that the court will not repeal the entire law. But that's what the Trump administration and the 18 Republican attorneys and governors prosecuting the suit are asking for. The ACA annulment must be seen as the policy of a party that at its national congress refused to produce any platform other than a declaration of allegiance to Trump.
Andrew Sprung writes about healthcare policy on his blog, ] xpostfactoid as well as in other publications .
David Anderson, MSPPM, is a research assistant at Duke University's Margolis Center for Health Policy.
Louise Norris is a partner in the Colorado Health Insurance Insider, and also writes about health insurance and health reform at healthinsurance.org and Verywell .