Next Effort to Repeal ACA Would Likely Look Like Last One

Young Mother Hugs A Crying Toddler In Hospital

Unsurprisingly, according to recent news reports (here and here), Congressional Republicans plan to pursue another attempt at repealing the Affordable Care Act next year if they maintain control of Congress after the midterm elections in November.

Any repeal effort would likely be based on the 2017 bills from Senators Cassidy and Graham and a somewhat similar plan outlined by conservative think tanks earlier this year.  The most recent Cassidy-Graham bill from September 2017, for example, would have added millions to the ranks of the uninsured overall, according to the Congressional Budget Office.  It would also have cut federal Medicaid spending by about $1 trillion over ten years, with millions fewer enrolled in the program.

Here’s a reminder of what such repeal plans would likely do:

  • Convert funding for the Affordable Care Act’s Medicaid expansion and marketplace subsidies to a highly inadequate block grant for states. The block grant amounts each state would initially receive would likely be well below what is now being spent on the Medicaid expansion and marketplace subsidies.  Moreover, the block grant amounts would likely fail to keep pace with rising health care costs and expected growth in enrollment and fail to adjust for greater demands due to a recession or a public health emergency.  States could also likely use the limited federal funding for coverage in inefficient ways, including supplanting existing state spending on other health care programs that have nothing to do with health coverage.  And, under the most recent Cassidy-Graham bill, the block grant would end entirely after 2026.
  • Impose a “per capita cap” on the remaining Medicaid program. Instead of the federal government picking up a fixed percentage of states’ Medicaid costs, the Cassidy-Graham bills would provide only a fixed amount of federal funding per Medicaid beneficiary, irrespective of states’ actual costs, with the amounts adjusted each year at a rate slower than projected growth in per-beneficiary costs.  That would result in deep Medicaid spending cuts, relative to current law, with the reductions growing larger over time.  In addition, the actual federal Medicaid funding cuts states would face could be even greater, if states face higher-than-expected per-beneficiary costs due to an epidemic or a new costly breakthrough drug or treatment.  As a result, states would either have to raise taxes considerably or slash other parts of their budget like education, or as is more likely, sharply cut their Medicaid programs in the areas of eligibility, benefits and provider payment rates.  Tens of millions of low-income children and families, seniors and people with disabilities would thus be at significant risk of losing their coverage or access to needed care.
  • Eliminate or significantly weaken key market reforms and consumer protections that now apply to the individual and small group markets under the ACA. For example, under the conservative think tank plan, insurers would no longer have to cover the “essential health benefits” meaning they can drop coverage of maternity care, mental health treatment, prescription drugs and therapy services as they did before the Affordable Care Act.  Moreover, while the think tank plan purports to leave in place the Affordable Care Act’s prohibition against denying coverage or charging higher premiums based on health status, insurers would no longer have to set premiums based on all their enrollees in all their plans (under the so-called single risk pool requirement).  This would allow insurers to charge lower premiums for skimpier plans, which would primarily attract younger and healthier people, while charging much higher premiums for more comprehensive plans that better meet the needs of those in poorer health or with chronic conditions.  That would drive up premiums for sicker people to potentially unaffordable levels.  In other words, the plan would likely effectively gut protections for people with pre-existing conditions over the long-run.  The most recent Cassidy-Graham bill goes further: states would also be given the option to allow insurers to explicitly charge higher premiums based on health status, although they could not allow insurers to deny coverage outright.
Edwin Park
Edwin Park is a Research Professor at the Georgetown University McCourt School of Public Policy.

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