After multiple failed attempts this year to repeal the Affordable Care Act, Congress has finally struck a blow. The tax cut legislation passed in the House and Senate this week includes elimination of the individual mandate.  Supporters of the ACA, and insurers participating in federal and state-based ACA marketplaces, have long contended that the only way to implement consumer protections in the ACA such as guaranteed issue (no exclusions for pre-existing conditions) is to ensure that everyone participate and obtain insurance. Absent the mandate, insurers and advocates believe fewer healthy people will participate, leading to rate increases for the less healthy population that remains in the market. 

The Congressional Budget Office (CBO) analysis of the tax legislation indicates that 13 million fewer people will be insured if the individual mandate of the ACA is repealed. Whether that number is accurate or an over estimation, the impact of the repeal is likely to begin immediately, even though the repeal of the mandate penalty does not become effective until 2019. But is it damaging enough to result in collapse of all of the other components of the ACA?

Repeal of the individual mandate is only the latest salvo in a concerted campaign to weaken the ACA on multiple fronts. Almost immediately upon taking office, the Trump Administration significantly curtailed advertising and outreach and reduced investment in sign-up assistance. Possibly the most effective curb on enrollment came from shortening the initial sign up period for 2018 from 3 months to just 6 weeks for those states using the federal marketplace. The District built and maintains its own marketplace, and its open enrollment continues through January 31, 2018. But DC very likely benefitted from past years’ federal level promotion of the ACA, and is feeling the corresponding lack of federal support in this current period.

Another blow to the ACA was the Trump administration’s decision to stop paying cost-sharing reduction payments to insurers. Uncertainty regarding the payments drove some insurers out of the market for 2018. Trump also loosened rules via executive order to allow for association and stop-gap health plans. Such plans do not have to offer the same benefits or protections of the ACA plans and so may be priced lower than ACA-compliant insurance. That makes them potentially attractive to young healthy people, contributing further to destabilization of the ACA marketplace.

Expansion of Medicaid was a key linchpin of the ACA, enrolling 12 million newly eligible patients. In the District, expansion resulted in approximately 75,000 new enrollees. While no changes to Medicaid expansion or requirements have emerged to date, House Speaker Paul Ryan has cued up Medicaid reform for 2018, and CMS has aggressively signaled willingness to approve state changes that include such elements as work requirements.

Given the multiple assaults on the ACA throughout 2017, can the ACA survive in 2018? While the road ahead is uncertain, aspects of the legislation remain popular, and in fact support for items such as no exclusions for pre-existing conditions, remaining on parents’ plans until age 26, and subsidies has only grown. DCPCA has hope that recent  and past action on the ACA will finally bring bipartisan attention to how Congress can do the hard, but possible (and essential) work of creating high quality, affordable care for all.