JAMA Forum: The 2014 Midterm Elections: Is the ACA Still a Political Flashpoint?

Aaron Carroll, MD, MS

Aaron Carroll, MD, MS

As this year’s national elections near, it’s striking how different the rhetoric around the Affordable Care Act (ACA) is from the last election. Even more noticeable is how different things are from 1 year ago. Parsing the way politicians are talking about the ACA and how data describe how it’s working may give us a clue to what to expect in the coming year.

Last year at this time, the media were covering the largely catastrophic rollouts of the insurance exchange websites. The websites were “buggy” and nearly impossible to use, and when a beneficiary actually completed an application, the data file that resulted was often unreadable and useless. Many ACA proponents began to worry that the inability to sign up for plans would lead to significantly reduced enrollment numbers.

That didn’t happen. By the end of the open enrollment period last April, about 8 million people had signed up for exchange plans. Since the Congressional Budget Office (CBO) had predicted 7 million people would sign up for plans in the first year, the administration surpassed its benchmarks.

Granted, some of these people who signed up for plans might not have paid for them. That’s the real metric of obtaining insurance. Some believed that a significant number of potential beneficiaries would welch on actually paying for plans. But by the summer, it seems that about 7.3 million people had paid for their plans, meaning that benchmarks had still been met and surpassed.

Many Newly Insured

Many claimed that those signing up for plans were already insured, but this assertion has been refuted by Kaiser Family Foundation surveys showing that a majority of enrollees were not insured before the ACA kicked into gear. Further, Gallup polls  and Commonwealth Fund surveys continue to find that the uninsured rate in the United States has decreased significantly in 2014.

Another concern was that preferentially sicker or older people would sign up for insurance or that regulations would make insurance much more costly than expected. Both of these issues would show up in significantly increased premium costs for 2015, and many predicted just that would occur. But a number of different analyses using a number of different methods have instead found that premiums appear to be increasing much more slowly than one would predict based on historical trends.

Given that the Obama Administration believes that more insurers will be joining the exchange marketplaces next year, there’s reason to believe that greater competition may help this trend even further.

Even overall health spending projections continue to come in lower than expected. Whether this is because of the ACA or trends outside its control is hard to say. But it seems that those concerned that the ACA would drive spending above the CBO’s predicted level don’t have much evidence to support that belief.

Medicaid Expansion Continues

The Medicaid expansion has only grown in the last year as well. Although many states have still refused to accept it as policy, in the past year, a number of states have reversed their decision to abstain. Indiana, Michigan, Pennsylvania, Iowa, Utah, and Tennessee all appear to be moving towards, or have achieved, some sort of compromise with the Department of Health and Human Services to accept some form of the expansion.

The reasons for this are, in many ways, economic ones. Hospitals in states with the Medicaid expansion are reporting greater increases in Medicaid admissions and greater decreases in uninsured admissions than those in states that refused the expansion. In fact, states that refused the expansion have seen uninsured admissions go up. Research shows that states that refuse the expansion aren’t only leaving billions of federal dollars on the table, they’re also increasing state spending on uncompensated care by more than a billion in 2016 alone.

It is for these reasons that the ACA seems to be much less of a hot button issue than it has been in previous years. This week, Governor John Kasich, a Republican, made a gaffe in the eyes of some conservatives when he told the Associated Press that the ACA would not be repealed, even if Republicans gained control of both the House and Congress. He later said that he was referring “only” to the Medicaid expansion when he made his remarks. But even that is an impressive change for a Republican governor. Not long ago, even the Medicaid expansion was viewed as an enormous and unacceptable expansion of government.

On the other hand, Senate Minority Leader Mitch McConnell (R, Ky) apparently believes that the ACA should go, but that kynect—his state’s exchange website—should remain. In other words, he’s more comfortable keeping the exchanges than the Medicaid expansion.

It’s much harder to take away benefits that already exist than to prevent their being provided beforehand. The most recent Kaiser Health Tracking Poll found that the ACA now ranks behind a number of other issues in terms of importance. The majority of registered voters said that they were “tired” of hearing Congressional candidates talk about the ACA and thought the candidates should focus on other things.

There are still a number of factors threatening the ACA’s long-term viability, including the many politicians who still want to see it repealed. These factors include a legal threat that still could lead to subsidies being denied to eligible individuals in many states. But it seems pretty evident that the fate of the ACA is much less threatened by this election than those that have come before.

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About the author: Aaron E. Carroll, MD, MS, is a health services researcher and the Vice Chair for Health Policy and Outcomes Research in the Department of Pediatrics at Indiana University School of Medicine. He blogs about health policy at The Incidental Economist and tweets at @aaronecarroll.

About The JAMA Forum:  JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.



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