Last year brought about what will hopefully be the final significant legislative effort to repeal and replace the Affordable Care Act. The culmination came just a few days before Christmas with the signing of a bill undoing a major element of the ACA - and it didn't even have the words "Obama," "healthcare," or "personal responsibility" in the title. Instead, the Tax and Jobs Act, signed by President Trump on December 22, effectively eliminated the individual mandate, providing the majority their first legislative victory after nine years of efforts to kill the ACA. For those scoring at home, that puts the Republican win-loss record against the ACA at 1-70. (See the Cleveland Browns? There's a team that's lost even more than you.).  

It was a victory that President Trump attempted to capitalize on, claiming soon after the signing that repealing the individual mandate meant Obamacare is "essentially" repealed . The reality is much more complicated.

I feel like 2017 has been like one long "bring out your dead" scene from Monty Python and the Holy Grail where the peasant insists he's not dead even though the man carrying him says he's not fooling anyone and he'll be stone dead any moment now.

Like that peasant, the ACA is very much NOT dead. It's alive and kicking. Seven years and counting. How has it survived? Lots of reasons, but here's two:

1. It's popular. The Kaiser Family Foundation has tracked ACA favorability since 2011, and 2017 marks the first year where more than 50% of respondents had a favorable impression. And that's despite all the efforts to undermine it last year.

2. Core ACA protections are still in place. The biggest question facing Republicans was: How would they kill the ACA when it had so many popular provisions? Turns out, they couldn't. Coverage until age 26, pre-existing condition protection, essential health benefit coverage, and subsidies are all still there.

Oh, and here's a fun fact about the individual mandate: it didn't really go away. The language is still sitting in the law. All the tax bill did was change the uninsured penalty to $0 (HR. 1, Part VIII, Sec. 11081(a)(2)(A)). Theoretically, a future Congress could plug in a new number and BOOM! the mandate is restored.

We won't know the healthcare impact of the mandate repeal for some time. But the financial impact of the bill that eliminated the mandate is already being felt. Companies that suffered a roller coaster ride in 2017 are now on more-solid ground. As a result, their financial outlook is improving. Since December 29, healthcare company stock prices have increased by 4%-5%.

So where do we go from here. I don't have the answers, and all the coffee cake in the world isn't going to help. That's because on top of all this, we still have core fundamental challenges within our healthcare system. I can't possibly go through them all so I'll let this Vox video do the work for me. It's a good five-minute watch. https://www.youtube.com/watch?v=tNla9nyRMmQ

There's plenty more to dissect. CHIP reauthorization is up next; Monday January 8 was 100 days since the program's funding expired. Entitlement "reform" isn't going away. States are being pushed to build more "personal responsibility" elements into their Medicaid programs (see below). And we've yet to address to opioid crisis and active duty service members are coming home to face new challenges as they transition to civilian life.  So hang on, there's a lot out there.

The hammer dropped Thursday when CMS clarified for states the hows and whys behind Medicaid work requirements. 

Beginning last March, CMS Director Seema Verma has made clear her intention to push Medicaid in this new direction, towards "personal responsibility." CMS has been quick to provide a rationale for this shift in Medicaid..

Many states are writing waivers to their Medicaid state plan integrating work requirements. Others had submitted waivers in the past only to see CMS under the Obama administration deny their application. Now the new administration is seeing this philosophical shift manifest itself in states, with Kentucky being the first.

Use KFF's Waiver Tracker to follow the c urrent status of waivers submitted or in process.

This is very troubling, especially for those in the disability community who see the programs that foster disability employment being used as leverage to push people off Medicaid.

CMS is walking a fine line by directing states to look at "able-bodied" Medicaid recipients while also acknowledging that many may actually have disabling conditions. This places pressure on states to determine the best form of employment supports for those that they feel must meet a work requirement. A recent analysis offers lessons learned from the experience of states who implemented work requirements for TANF.

Beneficiaries' Social Security awards and Medicare Part B premiums have both changed from 2017 to 2018. The Medicare Rights Center's "Dear Marci" newsletter had this helpful explanation of what that means to a recipient.

See also the  federal notice of SSI payment levels for 2018 versus 2017.

John Jansa

Smart Policy Works