Is the Glass Half Full or Glass Half Empty?

Earlier this month, the U.S. Senate voted 52 to 47 to repeal portions of the Affordable Care Act (ACA) also known as Obamacare.  The U.S. House of Representatives is expected to act by mid-December. 

If signed into law, this action would end coverage for 17 million individuals. The ACA would not be fully repealed, but it removes some key provisions.  Of particular interest are the plans to: 1) eliminate the subsidies provided to about 6 million Americans buying their insurance on the Marketplace when it is not offered by their employers; and 2) halt expansion of Medicaid by ending the federal subsidies over the next two years.   The Senate vote is the latest part of the five-year-long effort by Congress to veto all or parts of the ACA.  

When the bill hits the President's desk and it will be vetoed.  Let me say that again, the bill will be vetoed.  But the public debate will not end, it will simply move to the 2016 Presidential and Congressional election cycle.

Since the passage of the ACA in 2010, it has been challenged twice before the U.S. Supreme Court and legal challenges are ongoing in various courts around the country. 

The Supreme Court's first ruling in 2012 upheld that the health care law's requirement that most Americans obtain insurance or pay a penalty was authorized by Congress's power to levy taxes.  The court did decide that the ACA's requirement for states to expand Medicaid actually exceeded Congress' constitutional authority because of the threat to states' established eligibility to receive the existing federal payments.   A second Supreme Court ruling in 2015 confirmed that tax subsidies to help poor and middle-class people buy health insurance through the Marketplace applied nationwide, regardless of who operated the Marketplace.  

Following the 2012 ruling, many states did not expand their Medicaid program.  Fortunately, Arizona did expand the state's Medicaid program (known as AHCCCS) which became effective January 2014, resulting in almost 79,000 Arizonans now being enrolled in the program.  Arizona joined 30 other states in choosing to expand its Medicaid program.   Expansion discussions are underway in three other states (Utah, Wyoming and Louisiana).  According to the Kaiser Family Foundation, as of October of this year, more than 3 million people in the 17 states that didn't expand their Medicaid program and who don't qualify for the Marketplace are in the "Medicaid gap" without insurance coverage. 

The Marketplace is in the midst of its third year of Open Enrollment.  The Marketplace system has faced challenges beyond the premium tax credit question.  During the first enrollment cycle there were major computer problems that brought the system to its "knees".  Other challenges have resulted in some states that initially operated their own Marketplaces having thrown in the towel due to cost and technology demands.  Even with those major bumps in the road, last spring, on a national basis, nearly 11.7 million consumers obtained health insurance coverage through the Marketplace, according to the U.S. Department of Health and Human Services.  About 65 percent of those enrolled qualified for the premium tax credit and more than half paid $100 or less per month after those tax credits.  The outcomes for this year's enrollment cycle are not yet available, but analysts worry it will be increasingly difficult to "lure in" the remaining uninsured.

The ACA has faced other criticisms.  Just a flavor of those the concerns include:  1) news that premiums for this year increased to the point of making coverage out of reach for some families even with the premium tax credit; 2) the demise of Health Insurance Cooperatives in many states (including Arizona) because of the underpricing and the costs incurred by these start-ups; and, 3) United Health Care (the nation's largest single health insurance carrier) announcing a plan not to participate in offering insurance on the Marketplace next year.

There is, however, good news that can make us hopeful about the ACA.  Those outcomes include:  1) the percentage of individuals without health insurance has dropped; 2) the percentage who reported not being able to afford care has dropped; 3) there has been an increase in the number seeking preventative care; 4) an increase in the number who have a regular doctor and 5) a recent study has shown that more women are receiving early treatment for cervical cancer because of the ACA. 

It is still too early to know how these swirling changes will impact the ACA's future and ultimately access to health care for individuals either through employer sponsored health insurance, the Marketplace, Medicare or AHCCCS.  Our challenge and responsibility is to understand and participate in the public debate on the delivery of quality and efficient health care.