At last count, about 11.8 million people had signed up for 2018 coverage through the Affordable Care Act health insurance marketplace.
The high number – amounting to 96% of 2017’s total – surprised many: Americans had a halved timeframe (compared to the year prior) to select marketplace coverage for 2018 year, and the Department of Health and Human Services (HHS) deployed a much-reduced advertising effort than in earlier eras of the ACA’s existence.
Consumers’ continued interest in accessing and buying non-employer sponsored health coverage is good news for providers, making it more likely for patients to pursue care. But is the ACA still headed for trouble? Despite the many protections “Obamacare” has received over the years, certain government leaders continue to advocate against it.
Last year, legislators debated an ACA repeal to which only nine House Republicans dissented. But after an alternative plan – known as the Cassidy-Graham health-care bill – failed to inspire support among conservative or liberal legislators, efforts to dismantle the ACA were abandoned in September, at least temporarily. By December, the House had passed a tax bill that would repeal the individual mandate – the infamous provision in the ACA that requires individuals to have health insurance or face a penalty fee.
More recent tax cuts are also taking aim at the ACA: At the end of the three-day federal government shutdown in January 2018, President Trump signed a stop-gap budget plan that included $31 billion in tax cuts and a delay in implementing three taxes meant to fund ACA insurance coverage over the next 10 years. (Those being the medical device tax; the so-called “Cadillac tax” that taxes employers with more expensive health insurance plans; and the health insurance tax.)
Taken together with a repealed individual mandate, those tax cuts could put the healthcare system in an unsustainable situation: The ACA was designed to incentivize participation by both consumers and care providers; without the revenue of tax subsidies nor the impetus for healthy people to sign up and avoid paying a penalty, the economics of the system could break down – with expensive consequences to providers and patients alike.
At the moment, however, patients and providers are still watching to see how the ACA plays out. At least nine states are considering their own versions of an individual mandate. And at least one highly active marketplace insurer (Centene) has said they’re relatively unconcerned about the impact of a mandate repeal on their financials. For now, that signals that we likely won’t see payers pull out of the ACA system or drastically increase premiums in the near term.
And for as long as premium subsidies remain part of the system, we’re not in imminent danger of a so-called “death spiral” of the ACA. (With these subsidies, the premiums qualifying Americans pay are a given percentage of their income; everything above and beyond that is paid by federal tax credits.)
“As long as those tax credits remain the law of the land, there will be a stable group of people who want to be enrolled in this coverage, see it as a good deal, and try to take advantage of that and stay covered,” says Benjamin Sommers, associate professor of health policy and economics at the Harvard T.H. Chan School of Public Health. “That’s why I don’t think we’re in danger of the law imploding in the way that some suggest it will.”
And after a 2017 that included the failed Cassidy-Graham bill, strong marketplace-plan enrollment, and largely negative sentiment against legislators’ continued attempts to dismantle the ACA, 2018 may be a quieter year on the Affordable Care front.
Sommers, for one, says there is “probably not a lot of appetite” to chop away further at the ACA this year.
“The most popular parts of the ACA are still in effect, and the least popular part – the mandate – is gone,” says Sommers. “What’s left are things that people mostly are happy with: the tax credits, Medicaid expansion, essential health benefits, guaranteed coverage regardless of pre-existing conditions.”
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