Preserving the Affordable Care Act despite the headwinds

Despite a treacherous political environment that posed a direct threat to ACP's efforts to preserve the historic gains in coverage from the Affordable Care Act (ACA), a group of six medical societies was able to preserve key components of the program.

Sailors know that advancing and staying on course when their boats are facing strong headwinds and dangerous cross-currents is the true test of their sailing acumen. Looking back at ACP's advocacy in 2017, I think this is an apt metaphor to describe our achievements. We've been able to move our agenda forward despite the headwinds and currents of a treacherous political environment that posed a direct threat to several of our highest priorities, most notably ACP's efforts to preserve the historic gains in coverage from the Affordable Care Act (ACA).

Last year started with both President Trump and the GOP congressional leadership declaring that 2017 was to be the year when they would finally repeal and replace the ACA. Then, over and over again, “repeal and replace” bills were offered up that would have eliminated the key coverage programs and patient protections created by the ACA. Had any of them become law, federal funding for Medicaid expansion would have ended.

States would have been allowed to waive the ACA rules prohibiting insurers from charging more for preexisting conditions and/or imposing lifetime limits on coverage. Requirements that health plans cover essential benefits like cancer screening and prescription drugs would be repealed. The ACA's premium and cost-sharing subsidies to help people afford coverage in the individual insurance market would have been eliminated. Health plans would no longer have been required to cover essential benefits, like prescription drugs, cancer screening, or even physician and hospital visits. The bills differed on the details of what would have replaced these requirements, but they all would have gutted the ACA.

Yet here we are, more than a year later, and none of these provisions have been repealed. The ACA remains largely intact because each time, Congress fell short of the simple majorities in both the House and Senate needed to pass “repeal and replace.” Instead, Congress enacted only one change to the ACA: repeal of the requirement that individuals purchase qualified health insurance coverage (the individual mandate), which was included in the tax legislation signed into law by President Trump on Dec. 21, 2017.

This is not to say that repeal of the individual mandate is not a big deal; it is. Independent experts believe that it will result in substantial increases in premiums and loss of coverage for millions, which is why ACP strongly opposed repealing it as part of the tax law. However, because all of the other provisions of the ACA remain in effect, people who qualify for federal subsidies to buy coverage in the individual market will be protected from the premium increases, because by law, subsidies must keep pace with premiums. (It's people making more than 400% of the federal poverty level, $48,200 for an individual or $98,400 for a family of four, who will bear the brunt of the premium increases because they earn too much to qualify for subsidies.)

Yet let's not forget that even with repeal of the individual mandate, people who are covered by Medicaid, including in expansion states, will still be covered. People with preexisting conditions won't be turned down or charged more. Insurers will still have to cover essential benefits.

These accomplishments are a testament to the effectiveness of ACP advocacy. While no single organization can claim credit for stopping “repeal and replace,” ACP played a hugely important role. We, along with the American Academy of Family Physicians, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, American Osteopathic Association, and American Psychiatric Association, formed a physician coalition (informally deemed the “Group of 6”) that continually lobbied Congress against “repeal and replace” under the overarching principle of “first, do no harm” to patients. With a combined membership of over 560,000 physician and medical student members, the Group of 6 was and continues to be the largest physician voice on Capitol Hill fighting to preserve coverage for millions.

On our own, ACP launched numerous grassroots action alerts to members to influence key votes in Congress, lobbied Congress directly, promoted our views through social media platforms like Twitter and Facebook and through appearances on TV stations around the country, and wrote dozens of letters to Congress.

ACP also stepped in to help people enroll in coverage when the administration decided to cut funding and outreach during the shorter, 2018 marketplace enrollment cycle that ended on Dec. 15, 2017. By providing our members with state-specific resources to help their patients enroll, and by partnering in a consumer-driven social media campaign to get the word out to the public, ACP helped achieve what seemed to be impossible: Despite a 45-day enrollment period that was half as long as those of previous years, and notwithstanding the administration's hands-off approach to enrollment, more than eight million people enrolled in a qualified plan, just a tad lower than in 2016.

Our commitment to preserving and expanding coverage will continue to face headwinds this year. While Congress seems unlikely to have the votes needed to go back to full “repeal and replace,” the administration will likely use its regulatory authority to weaken essential benefit requirements, as it has already done with an interim final rule (still being challenged by ACP and others) that would allow employers to opt out of contraception coverage. It has created barriers to patients enrolling in Medicaid by allowing states to require that otherwise eligible persons be employed or document that they are seeking a job in order to receive benefits. Congress may try to impose cuts in Medicaid under the label of “entitlement reform.” On a positive note, Congress voted in late January to fund the Children's Health Insurance Program for six more years, ensuring that some nine million kids will be able to keep their coverage.

It's precisely when there are strong headwinds and treacherous cross-currents that skilled navigation and the courage to forge ahead are most needed, whether it's a journey across the seas or advocacy in Washington. ACP has shown that we have the skill and courage needed.