The Affordable Care Act (ACA) was designed like a puzzle with each provision necessary for the law to take shape and succeed, which is why it has been difficult for Congress to agree on changes to the landmark 2010 health insurance reform law, says UMass Medical School’s Robert W. Seifert, MPA.
The House of Representatives today voted to approve a revised version of the American Health Care Act (AHCA) presented by Republicans, and Seifert, principal of the Center for Health Law and Economics at UMass Medical School, explains why this has been a difficult path. Today’s vote came nearly six weeks after the first attempt to pass the AHCA.
While the AHCA does not repeal the ACA in its entirety, it will reduce subsidies that help individuals pay for insurance coverage and allows states to remove essential health benefits. The bill now heads to the Senate.
The ACA has been resilient, even with critics now in control of Congress and the White House, because of its highly interconnected nature, notes Seifert.
While opponents have vowed to dismantle the law “root and branch,” the various sections of the ACA are interwoven to such an extent that to remove one risks bringing the whole structure down, Seifert says.
“To take one of those pieces out, the entire house of cards would collapse,” says Seifert, who is the author and co-author of several public policy studies, both on cost containment and the rollout of the ACA in states across New England.
The expansion of health coverage for a wide swath of the population rests upon the individual mandate, under which those who can afford health insurance but decide not to buy it face an annual penalty, according to Seifert. (That fine is either 2.5 percent of household income or $695 percent per adult/$347.50 per child, whichever is higher.)
The individual mandate, in turn, depends on the premium and cost-sharing subsidies that are built into the plan to help those who can’t afford health insurance to be able to buy it. Those subsidies are, in part, supported by the ACA coverage penalties, as well as a number of other taxes and fees built into the plan.
If Congress were to remove a key piece or pieces of the plan and potentially cause the collapse of the entire ACA system, there would be significant fallout, Seifert believes.
“The effects would be many millions of people losing their health insurance, which at this point seems unpalatable to the American public,” Seifert says.
The AHCA version that passed the House today would enable states to get a waiver from the federal government from some of the ACA's core requirements, including one that mandates insurers cover people with pre-existing conditions and charge them the same as those without a chronic condition.
“The future of the ACA is not complete destruction but rather some modification, which may be extreme in some aspects of it,” Seifert said. “In terms of the entire law being at risk, I think we will see it live on in some form for the foreseeable future.”