ICYMI: ‘Five Reasons The ACA Won’t Be Repealed’

March 27, 2017

Late in 2016 – right after President Donald Trump was elected president and Republicans gained full control of Congress – many beltway-watchers were quick write about the inevitable demise of the Affordable Care Act (ACA).  But as Thorn Run’s Billy Wynne wrote in a December 2016 article for Health Affairs Blog, “the repeal and replace ‘two step’ [was] fraught with difficulty, bolder than the ACA itself, and far from certain to succeed.”

We were reminded of the intuition of this piece when Health Affairs reposted the piece on Twitter following the announcement that House Republicans had canceled a scheduled vote on their “repeal and replace” bill, the American Health Care Act (AHCA). Following that announcement, House Energy and Commerce (E&C) Committee Chairman Greg Walden (R-OR) conceded that “this bill is dead” in remarks to reporters.

Outlined below are a few of the key points made in that December 2016 article, ‘Five Reasons the ACA Won’t Be Repealed,’ along with some useful context on how things actually played out.

“ACA repeal has never meant repealing the entire law.”

Republicans in Congress were never able to achieve consensus about what “ACA repeal” actually entailed. As Billy pointed out, “in the replacement plans that have gone beyond a simple statement of ‘the ACA is repealed,’ there is scant reference to the Medicare reforms, workforce provisions, Medicaid program refinements, biosimilars pathway, or hundreds of other items that comprise the bulk of the law.” While many in the GOP were happy to keep most of those provisions intact, many of the popular insurance reforms proved to be the source of intra-party consternation. Ultimately, the House Freedom Caucus demanded that all of Title I of the ACA be repealed, which included popular provisions that Republicans ran on maintaining, including protections for patients with pre-existing conditions and allowing kids to remain on their parents’ insurance plans until age 26.

“There’s a reason the ACA is as complicated as it is. It had to be that way to work.”

The GOP ultimately attempted to walk a tightrope in their efforts to repeal and replace the ACA, seeking to keep politically popular provisions while removing others that necessarily underpinned the law. As the article pointed out, “the complexity comes in because these universally praised reforms are impossible without sufficient relatively healthy enrollees in the insurance market, thus requiring the mandate to buy insurance and the subsidies to make doing so affordable.” As the Congressional Budget Office (CBO) estimated, AHCA’s efforts to make coverage affordable and desirable would have fallen well short, leaving an estimated 24 million people without insurance coverage after 10 years.

“Ten states led by Republican governors, including Ohio, Michigan, and Indiana, have expanded Medicaid under the ACA.”

Among the most challenging decisions for Republicans in designing an ACA replacement was producing a plan that could placate Members of Congress in states that expanded Medicaid. Several Republican governors and GOP senators expressed concern with the House approach, which would have effectively ended the enhanced federal commitment to states that expanded Medicaid beginning in 2020. Even if Republicans in the House were able to pull enough levers to squeeze through the AHCA, this would have been a major sticking point in the Senate.

“There is no replacement plan.”

Republican leadership in Washington – including President Trump and the White House – ultimately lined up behind on a plan that was based largely on the framework outlined in Speaker Paul Ryan’s (R-WI) ‘A Better Way’ agenda. Ultimately, the plan wasn’t particularly popular among conservatives, moderates, or the vast majority of the American public (according to public polling). As Billy pointed out in December, “remember not long ago all that talk about the divide within the GOP over budget deficits, spending, the degree to which to invest in the middle class, etc.? Well, that divide hasn’t gone anywhere, and it’s about to come back to the fore in a big way.”

“.. the health care community—consumers, providers, companies, states, and more—will come together to oppose ACA repeal without a contemporaneous replacement plan that works.”

The lack of support from across the healthcare stakeholder community – along with fierce resistance from activists across the ideological spectrum – made it almost impossible for Republicans to shepherd their plan through Congress. The American Medical Association (AMA), the American Hospital Association (AHA), and AARP all opposed the House bill. Even conservative groups who have spent the last seven years railing against the ACA lined up against the AHCA, including Heritage Action, the Club for Growth, and the Koch brothers network. This confluence of opposition meant plenty of political cover for any Member of Congress who bucked leadership by opposing the bill.