Affordable Care Act One Year Later

It is hard to imagine that one year ago today President Obama signed into law the Affordable Care Act (ACA), the nation’s most sweeping reform since Medicare was passed in 1965.

 POLITICO ran a number of stories addressing health care reform and the impact that the ACA has had on Americans. Some of the stories were written by notable health care stakeholders, including Health and Human Services (HHS) Secretary Kathleen Sebelius, Senator Ron Wyden (D-OR), Senator Tom Harkin (D-IA), and Representative Steve King (R-IA). Below is a summary of each of these articles, as well as some additional commentary on recent developments in Congress relating to the ACA and health care reform.

Kathleen Sebelius

Ms. Sebelius asserted in her article that Americans “are enjoying new protections, greater freedoms and lower costs,” since the ACA was enacted. She noted how “children are now protected from being turned away by insurers because of a pre-existing condition and seniors enrolled in Medicare now have the freedom to get preventive care — such as mammograms and colonoscopies — for free.”

She also noted that “a Patient’s Bill of Rights is freeing families from some of the worst abuses of insurance companies, including cancelling coverage when you get sick because of a paperwork error.”

With respect to coverage and insurance, she noted that, “the number of small businesses offering coverage to employees is increasing.” Ms. Sebelius also added that the ACA is “demanding transparency and accountability from the insurance industry to bring down premiums.” For example, she noted how HHS has given states almost “$250 million in funding to strengthen their ability to review, revise or reject unreasonable insurance rate hikes.”

In addition, she pointed to “new proposed rules that would force many insurers to justify big increases and post explanations on the Web.” She also recognized that the new rules regarding medical loss ratio, requiring insurers to pay out 80-85 % of premium dollars on health care and quality improvement efforts — rather than marketing and executive bonuses.

In the future, the HHS Secretary noted that in 2014, individuals and small businesses will be able to bring down their health insurance rates through new state-based health insurance exchanges to. In addition, the ACA will give millions of eligible people tax credits, based on need, to help them afford health coverage.

Defending these changes, Ms. Sebelius pointed to data from the Congressional Budget Office (CBO), which showed that a family of four, making $55,000, could save more than $6,000 a year on health insurance in 2014.

Finally, the Secretary acknowledged the ACA’s investment in bringing down costs by investing “in preventive care, and innovative programs aimed at slowing that growth of premiums.” She asserted that new ides to “coordinate care, improve patient safety, and reduce waste, fraud and abuse, will create additional savings for decades to come.”

Interestingly, Ms. Sebelius acknowledged President Obama’s recent remarks at a hearing with governors, providers and patients, where the “president announced his support for legislation that allows states to pursue innovative alternatives to the law, provided they can achieve the same results as the Affordable Care Act — including relief from skyrocketing costs.”

Ultimately, Ms. Sebelius asserted that Americans “can’t afford to take away these benefits, cancel these rights, and return to the days when insurance companies got between you and your doctor.”

Senator Tom Harkin (D-IA)

Mr. Harkin echoed the comments of Secretary Sebelius, and noted that efforts to repeal the ACA are “misguided.” He claimed that “support for health care reform is growing steadily.” However, his article must have missed another POLITICO story that cited a recent survey from the Henry J. Kaiser Family Foundation, which found that 57% of independent voters had an unfavorable view of the law in January, up from 41% in December.

Nevertheless, the focus of his message was to put insurance companies on the hot seat. He noted that if the ACA is repealed, Americans will face discrimination based on pre-existing conditions and access to health insurance for more than 30 million Americans will be lost. Mr. Harkin pointed out that repealing the ACA would also “add hundreds of billions of dollars to the deficit by wiping out the savings in the ACA.”

Mr. Harkin specifically took issue with the provision of the ACA that ends denial of coverage due to pre-existing conditions. This issue is significant because “nearly half of nonelderly Americans have some type of pre-existing condition — like high blood pressure, arthritis or heart disease.” He also championed the ACA’s provisions that ban the practice of canceling policies when people get sick, prohibit insurers from imposing lifetime limits on benefits, and allow parents to keep their children on their policies until age 26.

In response to conservative attacks on the individual mandate, Senator Harkin noted that this provision is just “common sense.” Without this mandate, he noted that people will continue using emergency rooms for treatment and sticking other Americans with the bill—in fact, $1,100 a year to every family’s health insurance premiums comes from uncompensated care.

He noted how Mitt Romney, as governor of Massachusetts, put an individual mandate in his state’s health reform law to eliminate free riders and put everyone in the risk pool, to keep rates down for everyone. Mr. Harkin noted that, “this is the only way people with pre-existing conditions are not denied affordable coverage.”

Ultimately, Senator Harkin urged for continued support of the ACA, to insure that Americans have the freedom to afford a doctor, and so that people do not fear that a major illness will lead to financial ruin. While he admitted that the ACA is not perfect, and is more like “a starter home — suitable for improvement,” he noted that the ACA will replace the current sick care system with a genuine health care system — focused on wellness and prevention, which will reward health care providers for the quality of care they provide, not just the quantity.

As the law is implemented, he asked his colleagues who want to make sensible changes “to bring their tool kits, rather than their sledgehammers, so we can work together to improve the law.”

Senator Ron Wyden (D-OR)

The focus of Senator Wyden’s article was to discuss the bipartisan Empowering States to Innovate Act, which he introduced last year with Senator Scott Brown (R-MA) to advance states’ ability to make changes to the health reform law, has not lacked attention.

Mr. Wyden recognized how there has been too little focus on his bipartisan legislation because there is too much back and forth about whether President Obama is being inflexible (conservatives) or yielding too much (liberals).

In clarifying arguments against his proposed legislation, Mr. Wyden explained how “the legislation would make it easier for states to get waivers for health care reform and Medicaid and allow states to address both in one waiver request.” For example, he noted how a state could use the waiver process to cover Medicaid recipients as part of its new state private insurance exchanges. He further added that, “Wyden-Brown would also lock states into guaranteeing a generous and costly level of benefits.”

According to another article from POLITICO, the State Innovation Waivers will allow states to opt out of key health reform programs, like the mandated purchase of health insurance and building an insurance exchange, if they meet high benchmarks for coverage and affordability. Oregon and Vermont are expected to pursue these waivers and have secured the president’s support on moving their effective date to 2014 from 2017, when they currently kick in.

Consequently, Mr. Wyden noted how the idea of the Waiver for State Innovation provision was first part of his Healthy Americans Act that he introduced in 2006. He recognized then and now that states need “the flexibility to adapt federal health care laws to meet their regional needs,” because health care challenges are different in every part of the country.

Interestingly, Mr. Wyden noted that the provision is currently in the ACA, but wouldn’t take effect until 2017. Accordingly, “Wyden-Brown would allow states to start looking for ways to adapt and improve on the law now — while they are focused on its implementation — rather than years after those decisions and investments have been made.”

Mr. Wyden asserted that, “empowering governors and local lawmakers to improve the law is likely to make reform more successful for all Americans.” As a result, he noted that if states have the ability to invest their time and energy in finding ways to innovate and make health care reform work better, “all Americans would be healthier and more financially secure.”

In addition to innovation waivers, officials at HHS have approved no fewer than 1,040 requests for so-called mini-med waivers. However, the mini-med waivers — which allow people to keep insurance plans that have an annual payout on benefits of less than $750,000 — affect a relatively small group of the privately insured: 2.6 million people.

Moreover, many states over the next year will also seek a reprieve from two of the law’s most wide-reaching provisions: the medical loss ratio and the maintenance-of-effort provision. Last week, the agency granted Maine the country’s first medical-loss-ratio waiver, concluding the new regulation could drive insurers away from the state’s small individual insurance market.

POLITICO noted that HHS is weighing similar requests from New Hampshire, Nevada and Kentucky, and that “officials in a third of the states will ask Washington for waivers that will allow insurance companies to set aside more money for administration costs and profits. And more than half of the states are eying waiver requests to the Medicaid requirement.”

Additionally, more than two dozen Republican governors sent HHS a letter in January asking the secretary to waive the maintenance-of-effort provision, which bars states from dropping Medicaid eligibility before the program’s expansion in 2014.

Ultimately, the administration asserted that, “certain waivers and adjustments are necessary to ensure an orderly transition toward 2014, when most of the major health reform provisions come online.

Representative Steve King (R-IA)

Mr. King’s article primarily focused on amendments and legislation he has proposed in the House that would stop the automatic funding provisions of the ACA. Specifically, the ACA includes provisions, “unprecedented in scope,” which automatically spend $105.5 billion over the next 10 years to implement the law.

However, during the continuing resolution debate on funding the federal government for FY 2011, his amendments to cut off this funding were defeated. While two of his other amendments were adopted, which prevented ACA funds from being used to further the implementation of Obamacare, these provisions did not touch Obamacare’s automatic spending provisions. Accordingly, Mr. King emphasized the need to cut off these automatic spending provisions.

Consequently, he asserted that “if the president refuses to sign a continuing resolution that provides for responsible funding of all government functions except Obamacare, Americans will know that serving them is not his priority. Preserving his signature socialized medicine plan is.”

Accordingly, Mr. King explained how he and Representative Michele Bachmann (R-MN) are circulating a letter to House members for language to be in the FY 11 CR that would shut off both the annual and the automatic appropriations for ObamaCare’s implementation. The proposed language reads:

“Notwithstanding any other provision of law, none of the funds made available by this or any previous Act with respect to any fiscal year may be used to carry out the provisions of Public Law 111-148, Public Law 111-152, or any amendment made by either such Public Law.”

The letter also contains a pledge to vote against any CR that lacks this language and it asks that every member of Congress who supports repealing and defunding Obamacare sign the letter and take this pledge.

Rep. Dan Boren (D-Okla.) 

Representative Dan Boren discussed in his article why he voted against the Affordable Care Act and how just “17% of his constituents supported the law,” according to a survey conducted by Public Policy Polling in his district in March 2010. For Mr. Boren, the most disappointing part about the ACA was that there were many bipartisan issues that Republicans and Democrats agreed on, but instead of working on those issues incrementally, Democrats last year pushed a 2,000 page bill through Congress. He noted that the ACA has “dramatically expanded the federal government’s role in the private sector, placed burdensome mandates on small businesses and individuals and increased taxes during an economic downturn.”

As a result, Mr. Boren’s article discussed how he, along with Rep. Mike Rogers (R-Mich.), have introduced the Health Care Waiver Fairness Act. This legislation will allow every small-business owner or average American the opportunity to apply for a waiver from the new health care law if they so desire. The basics of this bill are that if you like the health care reform law, you can take advantage of it. If you want no part of it, you can opt out.

Discussion

Given the ongoing debate about repealing the ACA and constant changes in public perception and opinion about the ACA, the landscape for 2012 is shaping up to be a battle over health care reform. While many Americans are in favor of a number of the provisions—insurance for 26 year-olds, support on premiums for moderate-income Americans and better prescription drug coverage for seniors, no limits on pre-existing conditions, no lifetime limits—many Americans are still uncertain about the legislation.

Republicans will likely be running a campaign that attacks the ACA for being irresponsible and insufficient to address the growing health care costs and inefficiencies. While Democrats will emphasize the key provisions that have already taken effect and are helping Americans. Some say that Republican presidential candidates will likely run on repealing the bill, as many new members in the Senate and House did during the November 2010 elections.

There is also the added factor of the federal courts to issue rulings on the individual mandate, and with the Supreme Court leaning conservative right now, a decision from the federal judiciary finding the individual mandate unconstitutional may give Republicans the extra boost needed to win the election. And interestingly, a recent Kaiser Family Foundation poll found that nearly 90% of Republicans and 69% of independents want to repeal it. Even Democrats aren’t crazy about it — 51% want to repeal it, according to the same poll.

Ultimately, to repeal the ACA and change the political landscape of Congress and the implementation of health care reform, Republicans will have to come up with a replacement plan; a way to control rising Medicare costs, while also balancing the important provisions of the ACA that American’s support.