The Affordable Care Act turns 12 today, and it could look quite different by year 13

The Affordable Care Act turns 12 on Wednesday, and the tumultuous debate over its existence appears to be over.

Polls consistently find American majorities approve of the law. The Conservatives are running out of great constitutional challenges. Repeal is off the Republican agenda, and a few weeks ago, when Sen. Ron Johnson (R-Wis.) casually suggested that maybe Republicans should take it up, he quickly came back the statement with a press release stating that he didn’t really mean it.

But Year 13 could be tumultuous.

Officials in Washington and state capitals face a series of key decisions about the future of Obamacare, and depending on what they decide, literally millions of Americans could gain or lose health insurance — well that few people outside political and political circles seem to have noticed.

Here’s what’s at stake.

Make ACA improvements permanent

The US Bailout, the COVID-19 relief bill that Democrats passed and President Joe Biden signed into law in March 2021, increased the financial assistance available to people buying coverage on their own through or state-run exchanges such as Covered California.

This boost has made a big difference, reducing premiums by hundreds, if not thousands of dollars a year. But the additional financial assistance ends at the end of 2022, when premiums will go up for millions of insurance buyers unless Congress makes the increase permanent or at least extends it for a few years.

Joe Biden, as the October 2020 presidential candidate, delivers remarks on the Affordable Care Act and COVID-19 during a virtual briefing with medical experts in Wilmington, Delaware. Biden had promised to reinvigorate the Affordable Care Act.

Drew Angerer/Getty Images

A provision to do just that was part of the so-called Build Back Better legislation that President Joe Biden and Democrats in Congress crafted last year and looked set to pass — until December, when Sen. Joe Manchin (DW.Va.) raised a host of objections.

Biden and Democratic leaders say they are still working with Manchin on a compromise that would include at least some components of Build Back Better. Although the deal has been elusive so far, Manchin spoke positively about the health care provisions.

Furthermore, it would appear to be in his best interests — like all other Democrats — to avoid a large bonus hike for many of his constituents next year.

“No Democrat in the House or Senate has any doubt that the extension [the enhanced subsidies] is good policy. Eliot Fishman, senior director of health policy at FamiliesUSA, told HuffPost. “At the end of the day, I just can’t imagine them letting them expire.”

Closing the ACA’s “Medicaid Gap”

A dozen states, including Florida, Georgia and Texas, still haven’t extended Medicaid to cover all low-income residents, as originally provided for in the Affordable Care Act.

Rather than waiting for officials from those states to show up, Biden and Democrats have been discussing the possibility of the federal government directly insuring those people through some sort of federal action. More than 2 million people would thus become eligible for Medicaid, according to several estimates.

Build Back Better contained such a proposal. This too could be part of a possible compromise with Manchin.

The policy is not as simple as with the grant proposal. West Virginia already has an expanded Medicaid program, so Manchin voters wouldn’t benefit from it the way, say, Democratic Sens voters would. Jon Ossoff and Raphael Warnock in Georgia.

But Manchin has signaled that he still supports the provision, giving the expansion champions hope that it could eventually pass this year.

Solve the “Family Glitch”

Another way to strengthen the Affordable Care Act is through executive action. The Biden administration has already begun this process in order to respond to what has become known as “family glitch.”

Today, a group of more than 5 million low-income Americans cannot get subsidized insurance on exchanges, even though they have no way to get affordable coverage through An employer. The reason for this is the formula the federal government uses to determine eligibility ― and, in particular, how it prices coverage offered by employers. (Full explanation here For those who are interested.)

“Closing the Medicaid coverage gap and solving the family problem would end what the ACA planned to do 12 years ago.”

– Judith Solomon, Center for Budget and Policy Priorities

The formula works this way because of a regulatory decision by the Obama administration that many experts questioned at the time. The Biden administration has said it wants to rewrite the rules, and that effort is now underway, with a proposed rule now undergoing formal review in the Office of Management and Budget.

The process will take some time as the administration resolves ambiguities and disagreements about all it can – and should – do on its own. But even a partial solution could reduce the number of uninsured Americans, especially if some of the legislative proposals also become law.

“Closing the Medicaid coverage gap and solving the family problem would end what the ACA set out to do 12 years ago,” Judith Solomon, senior fellow at the Center on Budget and Policy Priorities, told HuffPost.

Reinforcement of rules on unwanted insurance

The Biden administration could also reverse some of the regulatory changes made by the Trump administration, starting with the Trump-era rules for “short-term/limited-duration” plans.

These plans have been around for a long time, and as the name suggests, their original purpose was to serve as a form of temporary protection for people who had short periods of coverage, say, because they were between jobs. They may not be available to people with pre-existing conditions, and they typically have coverage gaps that expose beneficiaries to large and potentially ruinous medical bills.

The Obama administration drafted rules limiting these plans to just 90 days, on the theory that the Affordable Care Act’s subsidized full coverage offer made short-term plans unnecessary. The Trump administration changed those regulations, pushing the maximum plan duration to one year and effectively allowing people to stay on short-term policies indefinitely through a series of renewals.

“‘Short-term’ plans sold for up to a year of coverage should have no place in a post-ACA world.”

– JoAnn Volk, Georgetown University Center on Health Insurance Reforms

The Trump administration’s argument was that these policies are cheaper, which they certainly are for some people. But just last week, the Commonwealth Fund released a report suggesting the proliferation of plans was weakening the actuarial balance of the Affordable Care Act trade-offs.

Meanwhile, people buying worn-out protection often don’t recognize its limitations, largely because companies promote the policies as an alternative to Obamacare.

“‘Short term’ plans sold for up to a year of coverage should have no place in a post-ACA world”, JoAnn Volk, a research professor at Georgetown University’s Center for Health Insurance Reforms, told HuffPost. “We have plenty of evidence that consumers buying these plans don’t know what they’re getting until they find out the hard way that they don’t cover what they need.”

Biden administration officials have signaled that reversing that rule is on their agenda. But the administration has yet to announce that it has started the process, leaving open the question of when — and if — it will.

Prevent a massive drop in Medicaid enrollment

Low-income people who qualify for Medicaid often don’t enroll — or, when they enroll, they drop out of the program because they’re confused about eligibility guidelines or struggle with enrollment paperwork. eligibility.

This can be a big problem during a pandemic, when people are in desperate need of health care, which is why the first-ever COVID-19 relief bill, which Congress passed and President Donald Trump signed into law in early 2020 prohibited states from automatically removing people from Medicaid rolls. .

The ban will end whenever the federal government declares an end to the COVID-19 state of emergency. (Biden administration officials have promised 60 days notice.) What happens to Medicaid rosters at this point will depend on how states handle the situation.

States may choose to take a slow and methodical approach, such as proactively communicating with registrants, confirming that databases contain up-to-date mailing addresses, and facilitating the registration of those now eligible for a subsidized private insurance. Or they may rush through the process without the same level of caution.

The Biden administration has required states to develop and file plans for how they intend to handle transformation, but as of January only half of states had done so, according to a survey by the Biden. Henry J. Kaiser Family Foundation. Without sufficient attention to the transition, more than 10 million people could lose their coverage, according to estimates by the Urban Institute.

“President Biden has undoubtedly delivered on his promise to reinvigorate the ACA, with record numbers of enrollments in the insurance market and Medicaid,” larry levittexecutive vice president of Kaiser Foundation, told HuffPost. “But if precautions are not taken as the public health emergency unfolds and Congress fails to extend enhanced premium assistance for ACA enrollees, recent coverage gains could be wiped out entirely. .”


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