The sweeping 2018 tax bill approved on Wednesday, December 20th, will repeal the individual mandate in 2019, which could potentially take millions of people out of the health insurance market.  It also eliminates some existing subsidies, halved the insurance enrollment period, squelched the plan’s marketing campaign, and rolled out regulatory health plans that changed the insurance landscape.

Advocates acknowledge that the ACA is weakened, but surviving – if in name only. Some insurers are finding their footing in the ACA markets — yet whether the health plans stay onboard or leave will determine if the law survives, and in what form.

Policy experts noted that the basic framework of the Affordable Care Act — the online marketplaces, the consumer protections, the subsidies that help millions afford insurance — remain in place, as does the Medicaid expansion, which brought insurance to about 12 million newly eligible people.  The expectation is that as long as that core survives, it can be rebuilt.

A big drawback of the existing ACA plan has been the requirement for Americans to get health coverage or pay a fine.  Through the new ACA mandate removed, they won’t be required to.  Dropping the individual mandate is one of the keys that opens the door to designing a better health policy.  Now this 2018 strategy will pick up repeal efforts where they left off earlier in the year.

Officials estimate the loss of the mandate means 13 million fewer people would be insured a decade from now.  But of course, not all health policy experts agree that it would have that destructive an effect.  Given the extreme debates over the past year, the mandate didn’t impose a big enough financial penalty on individuals to do what it was intended to do (namely, push enough young and healthy customers into the new insurance market to spread around the cost of covering the older and sicker ones.)

While the actual repeal of the mandate penalty won’t go into effect until 2019, many people think it’s immediate, and may skip getting covered for 2018.  This would dampen sign-ups, or discourage people to not pay their premiums, incorrectly thinking that the tax bill gives them a “get-out-of-insurance-free” card.

The ACA has also endured other changes involving enrollment, cost-sharing subsidies and loosened regulations.  And then there is the Medicaid outcome … all of which will be decided in 2018.  

Final numbers for the 2018 open enrollment that ended on 12-15-17 aren’t available yet but all signs point to a decline. While the enrollment was brisk, the timeframe was shorter for signups.  

Higher premiums also cast a cloud over enrollment —whether to keep “cost-sharing reduction” payments to insurers, which they use to bring down out-of-pocket costs for lower-income ACA customers. This uncertainty saw many health plans depart the market … causing less competition, less consumer choice — and higher premiums — among the plans that remained.

A number of states helped make up for the lost payments by subsidizing the ACA customers who got zero-premium insurance.  But the rising premiums — even if most people didn’t pay sticker price —this may not be enough to lure all the health plans back into a shrinking market.

A late-year decision allowed states to allow two new kinds of plans to compete with the ACA insurance policies — providing the exclusion of offering the full complement of ACA health benefits  (maternity, mental health, state-of-the-art cancer care, for instance).  Nor are these plans required to offer the same consumer protections such as coverage for a pre-existing condition. Both of these plans — association health plans for the small-group market, and yearlong stopgap plans — will probably draw the younger and healthier, leaving older and sicker people reliant on ACA plans, and driving up the prices.

One thing the ACA has proven since its enactment in 2010, is that it is resilient, despite perpetual attack. Its protections for people with pre-existing conditions and the working poor earned it a late-blooming popularity.

Right now doing away with the individual mandate makes the Affordable Care Act less workable.  Health Care in America will need focused, bipartisan negotiations going forward to fashion the best plan for our country.  We will all have to wait and see where the healthcare plan evolves next year.

Source: WSJ – 12-20-17