In recent days, multiple Republican bills to repeal or rollback the Affordable Care Act (ACA) failed to get enough votes on the U.S. Senate floor. It was a close vote. Senators came within one vote of sending a repeal bill to a two-house conference committee where all the most damaging proposals of recent months would presumably be considered. The repeal process unleashed one proposal after another estimated to result in millions of Americans losing coverage, including sweeping program changes and funding cuts for Medicaid, reduced premium assistance for low-income consumers to purchase coverage and changes to health insurance rules threatening many of the key consumer protections of the ACA and California law.
For now, the ACA remains. Credit goes to all the community voices, advocates, and experts who kept the pressure on elected officials and continued to call out the very real threats the proposals represented.
The threat is not entirely removed of course. Opportunities for federal officials to reverse, rollback or weaken the ACA and Medicaid through budget action, legislation or regulatory challenges will certainly present themselves over the coming months and years. To preserve California successes, and build on them, California health care leaders must continue to evaluate, educate and communicate the advances the state made and the opportunities for improvement that remain.
Here for consideration are some takeaways from the admittedly chaotic “repeal and replace” process.
ACA Successes Tell the Story
During Congressional debate on repealing the ACA, advocates, providers, and consumers focused on the transformations in the lives of real Americans because of the ACA. Whether in legislative hearings, town halls, media interviews or in contacts with federal representatives, the compelling stories of individuals and families securing health coverage, many for the first time, captured the attention of the media and the public. Every day in communities Americans learned about family members, friends, co-workers and neighbors with pre-existing conditions or access to medical care and treatments that were saving and improving lives. Hearing stories about real people made the ACA more concrete and made it less acceptable to roll back the gains of the ACA. California weighed in in the voices of state leaders, advocates and consumers with a compelling story to tell about developing a successful ACA marketplace, state investment in early implementation, state-specific market improvements and robust outreach and enrollment efforts around the state that cut the uninsured rate in half.
ACA Implementation (and the Effort to Repeal It) is Shifting Public Attitudes
Public support for the ACA shifted substantially over the past year so that a majority of Americans support continuation of ACA policies. Prior to passage of the ACA, a relatively small percentage of individuals navigated the process to secure individual coverage. Lots of consumers had no exposure to the standard pre-ACA insurer practices of coverage denials based on health status, soaring premiums for those in less than perfect health who had no alternative but to pay the premiums or go uninsured, and the low-value, low-benefit policies that characterized individual coverage. Similarly, until the repeal effort focused attention on the Medicaid program, and the substantial number of Americans who had gained coverage in states that expanded Medicaid under ACA, many Americans viewed the program as having little direct impact in most of their lives. The debate highlighted the broad reach of Medicaid into the lives of low-income individuals and families in both red and blue states and communities.
While there are still serious disagreements across the political spectrum about health care and the role of government in health care, more and more Americans believe that it is inherently unfair (potentially un-American) to exclude from coverage individuals with pre-existing health conditions or to charge these individuals or older individuals astronomically more for premiums. Growing numbers of consumers also believe that however it might be accomplished it is a worthy societal goal to get everyone covered. These views are evolving and increasing public expectation and support for strategies to accomplish the goal of universal or near-universal coverage. Although there is a long way to go before there is a societal wide consensus on these issues a lot of progress was made during this process.
Facts Matter – Education and Information are Key
Since passage of the ACA, and throughout the repeal debate, ACA opponents repeated slogans and talking point criticisms of imploding markets and the negative impact of the ACA on most American families. Some legislators supporting repeal also failed to acknowledge the potential real-world impacts or directly contradicted the expected consequences of ACA repeal and Medicaid cuts. Researchers, experts, philanthropy, and health care leaders consistently developed and disseminated timely analysis about the potential impacts of proposals under consideration to counteract misinformation. The Congressional Budget Office (CBO) analyses provided expert, independent information assessing the repeal proposals. While CBO was often criticized and dismissed by ACA opponents, the presentation of factual, analytical information helped to shape the public conversation and turn the tide of public opinion against the repeal proposals.
Improving ACA Will Protect It
While many of the criticisms and claims about the problems with the ACA were overstated, exaggerated, or manufactured, the American public and ACA proponents recognize there is work remaining to improve the ACA and the health care system. Individuals and families continue to experience high out-of-pocket costs and challenges in securing timely access to health care services. Health care costs and premiums continue to rise placing strains on families, and challenging health care providers and policymakers to meet the needs of communities. Before the repeal effort began in earnest, California was focused on taking ACA implementation to the next level through investment in access, quality, care management and community health improvement. We must stay the course in pressing for system-wide change even as we carefully monitor the shifting landscape threatening the progress to date. Ultimately, addressing access and quality issues, and the underlying causes of rising health care costs, will be essential to protecting the gains of the ACA. Failure to address these issues over time could erode the newly gained public support for the ACA.