For over 100 years, the unfinished business of creating a health care system that covers all Americans has raged on. With President Obama making this a top priority, in 2010 this effort took an unprecedented and giant step forward with passage of the Affordable Care Act (ACA). The ACA’s two main strategies to enable more affordable coverage were to finance and initially require Medicaid expansion to more adults and then create new state-based marketplace programs coupled with tax credits to enable wider purchase of private health coverage. Beyond these two major pillars, additional health insurance reforms extended health coverage to millions of previously uninsured people and more reliable coverage for those who were insured.
The popular provisions include allowing children/young adults to remain on their parent’s health plans through age 26 to finally eliminating the insurer-friendly practice of allowing drastically higher health insurance premiums based on pre-existing health conditions or imposing annual or lifetime caps on benefits. The ACA also put an end to the practice of denying health coverage to pregnant women at a one of the most crucial points in their lives.
In the landmark case Sibelius v. NFIB the Supreme Court upheld the ACA’s overall operation but eliminated the ACA’s mandate that states be required to expand Medicaid for parents and adults under 138 percent of the poverty level — leaving this battle to be fought out state by state. States that expanded Medicaid saw their rates of uninsured residents improve significantly, safety net and rural hospital finances improve, fewer women of childbearing age going without health insurance and more working people finally gain coverage. This state-by-state debate and the higher uninsured rates in non-expansion states made clear that not only were the ACA’s federal tax credits for purchasing private health insurance critical to helping Americans gain coverage but that Medicaid expansion was essential to the realization of President Obama’s and his allies’ vision for universal coverage.
And why did the ACA expand Medicaid as a critical way to help Americans get covered? It makes sense. Children were already covered by Medicaid across all states up to 138 percent of the poverty level, parents were covered at varying levels below poverty, and a handful of states covered all non-elderly adults under poverty through special “Section 1115” waivers. Medicaid expansion made changes enabling all family members to finally be covered together and used existing systems and provider networks designed to cover a lower income population – who face additional barriers to accessing care and a higher burden of disease.
These strategies have paid off. Recent data show that nearly 43 million Americans are covered by either Medicaid expansion plans (21.3 million people) or private plans with tax credits (21.4 million people)– all due to the ACA. Medicaid and tax credits available for private plans play virtually equal roles in lowering the nation’s rate of uninsured Americans.
Over time the Affordable Care Act has survived and prospered — and has become increasingly popular with voters of all political stripes despite numerous attempts to repeal it during its early years. As many remember the image of the late Sen. John McCain’s thumbs down, efforts to repeal the Affordable Care Act, which was at the top of the agenda for President Trump and his allies in Congress in 2017, did not go well.
Which is undoubtedly why candidate Trump gave conflicting statements during the campaign last year about his intentions regarding repealing the ACA this time around. However, the House passed the “One Big Beautiful Bill” Act and President Trump’s support for it underscores that the desire to undermine the ACA remains strong. The bill is squarely focused on rolling back the historic gains of the ACA through a functional repeal of its most important provisions, mainly through its multi-pronged attacks on both the Marketplace and Medicaid.
Our Georgetown colleagues at the Center on Health Insurance Reforms have blogged about the many ways in which the Marketplaces and tax credits are under attack in the reconciliation bill. And Republicans rejected an amendment in the House Ways and Means Committee designed to extend the enhanced premium tax credits, which have been crucial in driving up Marketplace enrollment and uninsured rates down to historic lows. Just released Congressional Budget Office estimates project that 16 million more people will become uninsured in 2034 as a result of the Medicaid cuts, changes to the Marketplaces, and failure to extend the ACA’s enhanced premium tax credits.
The reconciliation bill’s attacks on Medicaid are not limited to adults who have gotten coverage under the ACA’s Medicaid expansion. Our colleague Edwin Park’s comprehensive issue brief does an amazing job of running through all the Medicaid provisions in the bill and how they collectively make it much harder for millions of Americans to access affordable health coverage. But make no mistake, the proponents are doing their level best to bring down as much of the ACA’s coverage expansions as they can – without directly repealing the ACA outright thereby exposing them to unmanageable political anger.
Voters of all political stripes do not want to see Medicaid cuts as the President’s own pollster has pointed out. And Medicaid expansion has deep bipartisan appeal. When on state ballots, the question of expanding Medicaid has been passed by voters in multiple red states when voters have their say. And this bipartisan voter support for Medicaid is often despite the opposition of state leaders – a pattern continuing in Florida this year as the state debates Medicaid expansion.
The House-passed budget reconciliation bill also contains numerous provisions to discourage the remaining ten states (largely in the South) that have not expanded Medicaid from finally expanding coverage. This isn’t just a major policy change but a Congressional move of political jiu-jitsu with state Governors and legislative leaders having little room to respond. Leaders in these states will have a hard time explaining to their constituents why residents of neighboring states have better health coverage and more stable health care systems than they do.
Taken together, the provisions in the budget reconciliation bill amount to a backdoor attempt to repeal the Affordable Care Act and, if passed, will mean millions of Americans will lose health coverage. The shell of the ACA may be left standing – but the commitment to providing affordable health coverage to every American will have been shattered. Since states (led by Governors) each run their own Medicaid programs, the blame for health coverage loss, red-tape barriers, and cutbacks on care will likely fall more squarely on the shoulders of state leaders rather than on Congress.