MS Speaks

Friday Feedback: The Future of the ACA

By Molly Walker , Contributing Writer, MedPage Today

This week, we take a look at the mid-term election results, and how the new Republican majority in the Senate might potentially affect certain aspects of the Affordable Care Act (ACA). We reached out to health policy experts and healthcare professionals and asked:

"As Republicans take over control in the new Congress, there has been much speculation about what that shift will mean to the future of the ACA. Do you anticipate attempts to dismantle the ACA and, if so, how do you think that would be done?"

The participants this week are:

John Z. Ayanian, MD, MPP, Alice Hamilton Professor of Medicine, director, Institute for Healthcare Policy and Innovation, University of Michigan in Ann Arbor

David J. Becker, PhD, associate professor, healthcare organization and policy at the University of Alabama at Birmingham

Elizabeth Calhoun, PhD, MEd, associate vice president for population health sciences, executive director, Center for Population Science and Discovery at the Arizona Health Sciences Center at the University of Arizona in Tucson

Daniel Ehlke, PhD, MA, assistant professor, health policy and management, State University of New York-Downstate Medical Center School of Public Health, in Brooklyn

John S. O'Shea, MD, visiting fellow, health policy, at the Heritage Foundation in Washington, D.C.

Gail Wilensky, PhD, economist, senior fellow at Project HOPE in Milwood, Va.

Josh Zeitz, PhD, senior vice president and deputy director of the corporate practice at MWW, a public relations firm in New York City. He served previously as senior policy director to New Jersey Governor Jon Corzine

Unpopular Provisions May Yield Bipartisan Cooperation

Daniel Ehlke, PhD, MA: "The Senate under the leadership of Mitch McConnell is most likely to attempt to strip away less popular, or lesser known, portions of the legislation, like the medical device tax or elements of the employer insurance mandate, and bring them to a vote. After all, a vote to do away with some of the less popular aspects of the ACA could attract a few (or more) Democratic votes."

Gail Wilensky, PhD: "[Republicans] may also propose eliminating the device tax, which is regarded as a tax on new innovation if they can find another revenue source since there never was any justification for the tax other than needing more revenue, but that will be more challenging because of the revenue requirements given the upcoming expiration of the latest SGR 'patch.'"

Josh Zeitz, PhD: "There is, of course, the possibility that President Obama and the GOP Congress will come together to create patches or fixes to the ACA. There is limited bipartisan support for altering the employee mandate, the medical device tax, and the individual mandate. If both sides are willing to give a little and take a little, we might see substantive changes to the bill, though nothing approaching a major, structural overhaul."

David J. Becker, PhD: "Republican leaders would be wise to identify an agenda of key elements of the ACA they seek to modify or eliminate. Americans are looking for a change in tone from our elected leaders, and I think there is a tremendous opportunity here for Republicans to elevate the public discourse."

The Role of Medicaid Expansion

John Z. Ayanian, MD, MPP: "State governors will play an important role as congressional leaders consider the future of Medicaid under the ACA. Republican governors in states such as Arizona, Michigan, New Jersey, and Ohio have already expanded Medicaid. In the 23 states that have not expanded Medicaid, several Republican governors are reconsidering this option as physicians, nurses, and hospital leaders in their states are strongly advocating Medicaid expansion. Congressional leaders will also be influenced by this grassroots support for Medicaid in the ACA."

Elizabeth Calhoun, PhD, MEd: "The biggest driver of health insurance coverage was states' decisions whether or not to expand their Medicaid programs. Those that did saw their uninsured rates decline precipitously; among those that didn't, the rates have been largely steady. At the state level, among those that expanded Medicaid, hundreds of thousands of individuals that didn't have health insurance before are now covered and taking this away could prove politically risky, even in Republican-led states. While expansion states are grappling with issues of capacity and utilization, there is no doubt that, at the national level, access to healthcare has opened up to as many as 15 million people who didn't have it before."

John S. O'Shea, MD: "We will see efforts to stop or at least limit the Medicaid expansion. Providing coverage through Medicaid is not the same as providing healthcare, especially when reimbursement rates and administrative hassles make it all but impossible for doctors to treat these patients."

Medicare Reform

Wilensky: "Several measures which could change and potentially reform the ACA to make it more acceptable to Republicans include: substituting the Medicare strategy for inducing seniors to buy the voluntary parts of Medicare (that is, imposing a fee on those who don't purchase coverage during the first year it is available after losing comparable coverage) rather than mandating their purchase; limiting the reinsurance payments to those contributed by participating plans rather than potentially involving additional Federal funds; defining workers as those working 40 hours a week, or eliminating the employer mandate altogether; allowing people between the poverty line and 138% of the poverty line the option of using their Medicaid subsidy to purchase insurance in the exchange; and eliminating the IPAB [Independent Payment Advisory Board] which has many opponents in both parties."

O'Shea: "We can expect Congress to attempt to dismantle many of the more egregious provisions of the law, especially those that undermine the ability of doctors to provide the best care for their patients. This includes the IPAB (a board of government appointees who will decide which healthcare services are valuable enough to pay for). It should be repealed, and there is strong bipartisan support for repeal."

Becker: "Republicans may attempt to eliminate the IPAB which was to be tasked with developing recommendations to control the growth of Medicare spending. The IPAB has never actually been formed, and currently Medicare spending growth has been at historically low levels. The IPAB was conceived as an effort to separate the important task of designing policies to control Medicare spending growth from the political pressures of Congress. If Republicans attempt to eliminate the IPAB, they will need to offer a clear and compelling alternative approach to Medicare cost control."

Future Challenges

Zeitz: "The only remaining threat to the ACA is a pending challenge in the federal courts to the eligibility of federal exchange participants to receive subsidies. Even if the Supreme Court were to deal a blow to the administration, most states currently using the federal program would summarily designate healthcare.gov as their official state exchange, and the Obama administration would recognize the fix administratively. The takeaway: Obamacare has another 2 years to sink its roots. By 2017, when President Obama leaves office, it will be all but impossible for conservatives to achieve their stated goal of repeal."

Ehlke: "President Obama will continue to wield the veto pen and does not seem afraid to use it. The ACA will, however, be in much greater peril under a Republican presidential successor, assuming continued GOP control of both houses of Congress. "