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Wading through the news: What parts of the ACA are in jeopardy?

Wading through the news: What parts of the ACA are in jeopardy?

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Will Republican victories reshape the ACA?
Will Republican victories reshape the ACA? Speculation runs rampant.

Last week’s midterm election – and the shift in power it brought — has generated a flurry of speculation regarding the Affordable Care Act. 

House Speaker John Boehner’s post-election speech immediately triggered questions about the ACA’s future: “The House, I'm sure, at some point next year will vote to repeal Obamacare because it should be repealed.” Along with the individual mandate, he went on to say there was support to repeal or replace various aspects of the law, including the definition of a full-time workweek, the medical device tax, and the Independent Payment Advisory Board (IPAB), which is tasked with achieving Medicare savings.

So, is Obamacare really at risk? The short answer is that the core of the law will likely survive, thanks to the presidential veto power and the Senate’s ability to support it. Still, with the new balance in power, sections of it could be pruned away by the legislature.

Here are some key pieces that could be subject to some legislative chipping:

1. Tax on medical devices: This 2.3 percent tax on medical devices such as artificial hips helps fund the ACA. Repealing the measure could have bipartisan support, explains this post from Roll Call. Critics say the tax harms competition, stifles innovation, and adds to health costs. But cutting it could deal a significant blow to the health law’s funding, as Mary Agnes Carey, a senior correspondent for Kaiser Health News, explains in this NPR interview:

But here's the problem — it fills about a $28 billion revenue hole over 10 years. So if you repeal the medical device tax, you have less money to finance the health care law and, also, the other industries that are taxed in the law are certainly going to come up and ask for their reductions, whether it's the health insurers, the drug makers and so on.

2. Defining a full-time work week: Another aspect Republicans could tackle is the employer mandate, which says companies with more than 50 full-time employees (FTEs), have to provide health insurance. A FTE is defined as someone who works at least 30 hours a week. This provision has been criticized for being a job killer and for encouraging companies to convert workers to part-time employees.

Congress could change this provision by increasing the number of hours that defines a FTE to 40. In this post from the Association of Health Care Journalists, Joanne Kenan writes that the GOP could instead try to repeal the entire employer mandate, which requires that businesses with more than 50 workers offer affordable coverage.

3. Independent Payment Advisory Board (IPAB): This 15-member appointed body, which is designed to reduce Medicare spending, could be in jeopardy as well. The body hasn’t been needed yet, since Medicare spending increases have been lower than expected. Critics – on both sides of the political aisle – perceive the board’s creation as usurping Congress’s legislative authority, while supporters say an independent body is better suited for the job than Congress. The health law stipulates a very small window for any measure to abolish this board, beginning in 2017 with passage required by August.  Those are the immediately obvious aspects of the health law that the media has been highlighting. But “trendy topics” aren’t the only aspects that could use pruning writes Scott Gottlieb, a physician and a resident fellow at the American Enterprise Institute, a conservative think tank in Washington. In a piece for Forbes, Gottlieb says observers should also be on the watch for changes that could improve the health law’s overall purpose – or at least better position Republicans to offer an alternative.   

…[E]ven the Act’s enthusiasts concede, that there are parts of Obamacare that are disliked, gratuitous, or simply unfeasible … If Republican’s are organized and strategic, they can start cutting away at the most necrotic aspects of Obamacare, while at the same time erecting a better skeleton on which to hang their own market-based alternative — should they get control of the White House in 2016.

Gottlieb points to measures such as giving states more freedom over how they use Medicaid money and relaxing tight federal control over the types of health plans available on state exchanges. That, he says, would give consumers more choices instead of a standardized benefits package, with differences lying largely in the cost of premiums and deductibles.

Regardless of how the ACA may change, the consensus is that it will live on.

Kaiser Family Foundation CEO Drew Altman, writing in The Wall Street Journal, dismisses much of these potential legislative efforts as “the concerns of insiders” that would have little impact on the core of the health law, and urges journalists to put those pieces into perspective:

As proposals to modify the ACA are introduced in the new Congress, it will be critical for the media to provide perspective, explain what proposals mean for people, and distinguish between small changes and ones that would cut to the core of the law.

Photo by Gage Skidmore via Flickr


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