For seven years, Republicans vowed they would repeal and replace Obamacare. President Donald Trump campaigned under that banner, calling the Affordable Care Act a disaster that had failed Americans.
In the end, there was no repeal.
The GOP did score a victory at the 11th hour and zeroed out the individual mandate penalty in their tax bill. Starting in 2019, people who might be able to afford insurance but choose not to buy it no longer face a fine.
But insurance subsidies for families of modest means and expanded Medicaid — two of the key pillars of Obamacare — remain intact.
Limited success has been the overall pattern for Trump’s 12 health care promises in his first year. Half are rated In the Works and the other half are Stalled.
Trump’s efforts produced more uncertainty about the future outlines of health care, but for now, the first year of full Republican control of Congress and the White House has left Americans with a health care landscape that largely resembles the one they knew before the election.
Some major action is waiting in the wings, a big one being rules that would let people buy limited, and cheaper, insurance policies. The battle over health care is far from over. If nothing else, the struggle in 2017 left us with some takeaways that highlight what to watch in 2018.
Trump got ahead of himself when he proclaimed that repealing the individual mandate “essentially repealed Obamacare,” a claim we rated False. Still, Republicans can go back to their states and their districts and say that they delivered at least a down payment on a defining pledge.
We rated Trump’s promise to repeal Obamacare In the Works.
Gail Wilensky, the head of Medicare and Medicaid under President George H.W. Bush, said the Affordable Care Act has proven resilient.
“The ACA is not going away,” Wilensky said. “We have no history of taking away an expanded benefit once it’s been in place for two or three years. It’s a big lesson, but at one level, it shouldn’t be surprising. The optics of having Republicans in full control led to expectations that were unrealistic.”
What allowed the Affordable Care Act to take root?
In part, the law defined success as the number of people with insurance, said Robert Blendon at Harvard’s School of Public Health. The Congressional Budget Office estimated that the first version of the House’s health care legislation would leave 24 million more people uninsured. The estimate for full repeal was 32 million. There were Republican governors, such as Ohio’s John Kasich, who lobbied against rolling back the law’s coverage gains.
“The principle that came out is that you cannot take insurance away from 25 million or 30 million people,” Blendon said.
The political meaning of that lesson is a matter of debate.
Blendon said it leaves wide latitude for defining what counts as coverage, and it doesn’t mean Obamacare itself enjoys broad support.
But health policy professor Sherry Glied at New York University said the assault on the law forged a constituency that hadn’t existed before.
“All of a sudden these people can identify with one another,” Glied said. “They see how the law has helped them. They start showing up at town halls across the country and the stories of what will happen to them show up in the newspapers because they’re human interest stories.”
The polling provides ammunition for both sides. The Kaiser Health Tracking poll found approval for the Affordable Care Act broke the 50 percent mark for the first time since 2011. On the other hand, approval continues to hover around that point, reflecting limited enthusiasm.
Trump’s first year saw a shakeout in the individual market. Several large insurance companies, including Aetna, UnitedHealth Group and Humana said they wouldn’t sell individual policies on the government insurance exchanges. Trump and House Speaker Paul Ryan talked about Obamacare going into a death spiral. We rated those claims Mostly False.
Trump canceled millions of dollars in reimbursements — called cost-sharing reductions — to insurance companies that had paid doctors and hospitals for treating their policyholders. He also cut the 2018 ACA marketing budget by 90 percent and shortened the signup period.
Each of those steps attempted to undercut the federal health insurance exchanges. There was much talk about “bare counties,” places where residents would find no carrier selling a policy at any price.
Ultimately, every county was covered, although many had just one provider, meaning there was no competition. Signups on the federal exchange exceeded predictions, with a bit over 8.7 million people getting policies, with more to come through the state-run exchanges.
“We now have clear evidence that insurers' financial performance in the individual market has improved sharply during 2017,” said Matthew Fiedler, a health policy researcher at the Brookings Institution. “My estimate is that insurers will roughly break even or do a bit better on ACA-compliant individual market plans in 2017.”
Fiedler warned that the end of the individual mandate and continued uncertainty over the cost-sharing payments puts a cloud over what happens next.
Pending regulations that could open the door to skimpier but cheaper insurance plans have the potential to up-end insurance markets.
Trump called for those new regulations in an executive order. Depending on what they say, they could deliver on his promise to allow insurance companies to sell across state lines. We rated that In the Works.
The effort to repeal and replace Obamacare drew attention to Medicaid, a pillar of the law that is often lost in the rhetoric over the state of the insurance market. Extending the program for the poor to all adults who make as much as 138 percent of the federal poverty level accounted for the single-largest rise in the number of people with insurance — about 13 million by congressional estimates.
Republicans aimed to do more than rein in Medicaid expansion; they tried to curtail future spending growth by converting one of the government’s top three entitlement programs into a block grant to the states.
But in doing that, they put a spotlight on the number of people in nursing homes who count on Medicaid to pay their bills.
“It brought a lot of new stakeholders into the debate,” said Daniel Polsky, a health economist at the University of Pennsylvania. “No longer is it this low-income population. A lot of people on Medicaid are your own grandmothers. There’s a lot of children on the Children’s Health Insurance Program. It wasn’t just ‘them’ over there. It was your neighbor.”
Trump’s promise to administer Medicaid through block grants rates Stalled.
A repeat of the drive to repeal and replace seems unlikely. Senate Majority Leader Mitch McConnell, R-Ky., told reporters he doesn’t see the Senate taking up the cause again.
The action, Harvard’s Blendon said, will likely be in the states.
“It’s very hard to see that anything significant will change before the election,” Blendon said. “The administration will continue to try to erode coverage and give states waivers to add things like work requirements to Medicaid.”
The Trump administration issued guidelines Jan. 11 clearing the way for states to do that if they wish.
In the Senate, there’s some support for a bill to restore the reimbursements to insurance companies that Trump canceled. The main beneficiaries would be the 6 million to 7 million people who make too much to qualify for premium subsidies. But that bill faces stiff opposition from Republicans who see it, incorrectly, as an insurance company bailout.
For Fiedler at Brookings, the single-biggest move to watch involves loosening the rules on insurance plans.
“I would expect a large exodus of healthier people into these plans,” Fielder said. “That would mean much higher costs for sicker people with incomes too high to qualify for subsidies, as well as higher subsidy costs for the federal government.”
The administration took a step in that direction with its Jan. 5 proposal to ease the rules on association health plans. Such plans are insurance set up by professions or clusters of small employers. You might see groups organized by home remodelers, accounting firms or some other line of work. The administration’s proposal retains protections on pre-existing conditions but would allow plans to cherry-pick the benefits they offer.
Trump might not have delivered on his promises, but he successfully created more uncertainty about the future outlines of health care.
The change in the short-run is modest. The changes in 2018 could be pivotal.
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