Presidential election puts Affordable Care Act back in focus

This is a story from KFF Health News.

Health care is suddenly the focus of the final sprint to the presidential election, and the outcome will shape the Affordable Care Act (ACA) and the coverage it provides to more than 40 million people.

Besides reproductive rights, health care remained in the shadows for most of the campaign. However, recent comments from former President Donald Trump and his running mate, Ohio Sen. JD Vance, about possible changes to the ACA have exposed Republicans to greater scrutiny.

More than 1,500 doctors across the country recently released a letter calling on Trump to reveal details about how he would change the ACA, saying the information is necessary for voters to make an informed decision. The letter came from the Committee to Protect Health Care, a national advocacy group for doctors.

“It’s remarkable that a decade and a half after the ACA passed, we’re still debating these fundamental questions,” said Larry Levitt, executive vice president of health policy at KFF, a nonprofit organization. health news provider that includes KFF Health News. “Democrats want to protect people with pre-existing conditions, which requires money and regulation. Republicans have sought to reduce federal regulation, resulting in fewer protections.”

The two parties’ positions have very different goals for the ACA, a sweeping law passed under former President Barack Obama that sets minimum benefit standards, makes more people eligible for Medicaid and ensures that consumers with health problems pre-existing health conditions cannot be refused health coverage.

Vice President Kamala Harris, who previously supported a universal health care plan, wants to expand and strengthen the health law, known as Obamacare. She supports providing enhanced permanent and temporary subsidies that reduce the cost of premiums. And she is expected to pressure Congress to expand Medicaid coverage to more people in the 10 states that have not yet expanded the program.

Trump, who has repeatedly tried unsuccessfully to repeal the ACA, said during the September presidential debate that he had “the idea of ​​a plan” to replace or change the legislation. Although this phrase became a bit of a laugh line because Trump promised an alternative health insurance plan several times during his administration and never delivered on his promises, Vance later provided more details.

He said the incoming Trump administration would deregulate insurance markets — a change that some health analysts say could provide more choices but erode protections for people with preexisting conditions. He appeared to adjust his position during the vice presidential debate, saying the ACA’s protections for pre-existing conditions should be left in place.

Such health policy changes could be proposed as part of a broad tax measure in 2025, Sen. Tom Cotton (R-Ark.) told NBC News. It could also open the door to changes in Medicaid.

Conservatives have long sought to overhaul the health insurance program for low-income or disabled people from the current system, in which the federal government contributes according to a formula, a percentage of states’ total Medicaid costs, to a system that caps federal spending through block grants or block grants. per capita funding limits. Supporters of the ACA say it would shift significant costs to states and force most, if not all, states to abandon expanding the program over time.

Democrats are trying to turn the comments into a political liability for Trump, with the Harris campaign running ads claiming Trump doesn’t have a health care plan to replace the ACA. Harris’ campaign also released a 43-page report, “The Trump-Vance ‘Concept’ on Health Care,” claiming that her opponents would “take away coverage from people with pre-existing conditions and raise costs for millions of people.” people “.

Republicans have stumbled in the past when unsuccessfully seeking to repeal the ACA. Instead, the law became more popular and the risk Republicans posed to pre-existing condition protections helped Democrats regain control of the House in 2018.

In a KFF poll last winter, two-thirds of the population said it was very important to maintain the legal ban on charging people with health problems more for health insurance or denying their coverage .

“People in this election are focused on issues that affect their families,” said Robert Blendon, professor emeritus of health policy and political analysis at Harvard. “If people think their own insurance will be affected by Trump, that might matter.”

Vance, in a Sept. 15 interview with NBC’s “Meet the Press,” tried to downplay that impact.

“You want to make sure that pre-existing coverage – conditions – are covered, you want to make sure that people have access to the doctors that they need and you also want to implement a deregulation program so that people can choose a plan health care. it suits them,” he said.

Vance added that the best way to ensure everyone is covered is to promote greater choice and not put everyone in the same insurance risk group.

Risk pools are fundamental in insurance. They refer to a group of people who share the burden of healthcare costs.

Under the ACA, enrollees are generally in the same pool regardless of their health or pre-existing conditions. This is done to control premium costs for everyone by using the lower costs borne by healthy participants to control the higher costs borne by unhealthy participants. Separating sicker people into their own pool can result in higher costs for people with chronic illnesses, potentially putting coverage out of their financial reach.

The Harris campaign has seized on the threat, saying in its recent report that “health insurers will resume discriminating on the basis of your health or poor health.”

However, some critics of the ACA believe there are ways to separate risk groups without compromising coverage.

“Unsurprisingly, this has been exaggerated for political purposes,” said Theo Merkel, a former Trump aide who is now a senior fellow at the Paragon Health Institute, a right-wing organization that produces health research and policy proposals based on on the market. .

Adding short-term plans to coverage options won’t hurt the ACA market and will give consumers more affordable options, said Merkel, who is also a senior fellow at the Manhattan Institute. The Trump administration increased the maximum duration of these plans, then Biden reduced it to four months.

People eligible for subsidies would likely purchase comprehensive ACA plans because — with the financial assistance — they would be affordable. So the ACA market and its protections against pre-existing conditions would continue to work, Merkel said. But also offering short-term plans would provide a more affordable option for people who don’t qualify for subsidies and who would be more likely to purchase substandard plans.

He also said that in states that allowed people to buy non-ACA-compliant plans outside of the exchange, the exchanges worked better than in states that banned it. Another option, Merkel said, would be a reinsurance program similar to the one in place in Alaska. Under the plan, the state reimburses insurers for covering very expensive health claims, helping to keep premiums affordable.

But ACA supporters say that separating sick and healthy people into different insurance risk groups will make health coverage unaffordable for people with chronic illnesses, and that allowing people to purchase health plans short term for longer durations will backfire.

“It doesn’t protect people when they get sick,” said Leslie Dach, executive president of Protect Our Care, which advocates for the health law. “There is no reason to do this. It is unacceptable and makes no economic sense. They will hide behind saying ‘we are making things better’, but that is all false.”

Harris, meanwhile, wants to preserve the temporarily expanded subsidies that helped more people get lower-cost health coverage under the ACA. These expanded grants, which help about 20 million people, will expire at the end of 2025, setting the stage for a pitched battle in Congress between Republicans who want to let them run out and Democrats who say they should be made permanent.

Democrats introduced a bill in September to make them permanent. One challenge: The Congressional Budget Office has estimated that it would increase the federal deficit by more than $330 billion over 10 years.

Ultimately, the ability of either candidate to significantly expand or change the ACA rests with Congress. Polls suggest Republicans are in a good position to take control of the Senate, with the outcome in the House more uncertain. However, margins will likely be tight. Regardless, many initiatives, such as expanding or restricting short-term health plans, can also be advanced through executive orders and regulations, as Trump and Biden have done.