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The 2018 midterm elections meant the end of the GOP’s decade-long efforts to repeal the Affordable Care Act.

With Democrats in control of the House, the ACA has survived.

But it’s wounded. And it still faces grave uncertainty from the lawsuit brought by conservative states and backed in part by the Trump Administration’s Department of Justice. A federal judge in December 2018 ruled that the entire law – each and every provision – should be thrown out now that Congress has eliminated the individual mandate penalty. Most legal experts doubt that will be upheld but pieces of the law, including the popular protections for people with pre-existing conditions, could be in jeopardy. The appeals process could take months if not years, adding more damaging questions about the ACA’s future.

Both through legislation and executive action, the GOP and the Trump administration have inflicted heavy damage since early 2017, Uncertainty about the law’s future, combined with the cessation of the Cost-Sharing Reduction Subsidies, had prompted major insurers to flee many state markets for 2018 – although insurer participation grew modestly for 2019 and premiums stabilized.  For 2019, the law has new challenges. The repeal of the individual mandate penalty and new rules that allow the sale of skimpier health plans that don’t comply with ACA regulations are likely to further segment the market, with healthier people peeling off and older and sicker people staying in the ACA exchanges. Congress also has suspended several taxes that are supposed to pay for the legislation, opening it to yet more political attacks on fiscal grounds. For millions of people with subsidies, the ACA will continue to be attractive – it won’t “implode” as critics have predicted. But fixing it, restoring it to its authors’ original vision, would require effort and compromise – which is not at all likely given that one party has spent the better part of a decade intent on the law’s destruction.

The ACA began with higher hopes. For decades, U.S. legislators struggled with how to ensure all Americans had health insurance. Every other developed country – and many less developed ones – had some kind of universal or near-universal coverage. On March 23, 2010, President Barack Obama signed the Patient Protection and Affordable Care Act, commonly shortened to Affordable Care Act (ACA) or “Obamacare” – a term that was derogatory at the start but eventually even Obama embraced it.

Back in 2010, when the law was enacted, the ACA was forecast to cover about 32 million Americans by 2019, a forecast that gradually dropped amid barriers to implementation and persistent political opposition. Political and policy uncertainties have shadowed, threatened and changed implementation. The political fights around the law during the Obama administration led to two major Supreme Court challenges. The court in 2012 upheld its constitutionality – but ruled that the Medicaid expansion was optional for the states. That turned out to have long-lasting implications. As of late 2018, 14 states still had not expanded (although Idaho, Nebraska and Utah voted to do so in November, and several states including Kansas elected new governors who back expansion). The refusal to expand affects both the coverage in those states and the financial health of their hospitals and other providers. The second Supreme Court case, King v. Burwell, challenged a core provision – the insurance subsidies for millions of Americans getting covered through – but in June 2015 the court upheld the subsidies. At the time it was seen as the last existential challenge to the law. Then came the 2016 election – and Donald Trump.

Throughout all the conflict, one thing has been clear. Whatever the law’s flaws and setbacks, it has led to historic gains in coverage, even in the states that shunned Medicaid expansion. CDC data (released in late 2017 and covering 2016 – before Trump) found that the uninsurance rate had dropped to about 9 percent; for nonelderly adults (aged 18-64) the rate had dropped from 22.3 percent in 2010 to 12.4 percent in 2016. Partial, early results for 2018 show coverage remains robust (probably partly because of a strong job market, where many get covered) – uninsurance is 8.8 percent. More than 20 million people had gained coverage. There is still wide variation among states. For instance, in Massachusetts just 3.2 percent were uninsured, compared with just less than 21 percent in Texas in 2016. (Critics point out that roughly 30 million people are still uncovered (including undocumented immigrants who are ineligible for coverage). But without the ACA, the government had projected there would have been 57 million.

Medicaid isn’t the only way that conservative states have resisted. About 2/3 of the states decided they would not or could not run all or parts of the health insurance exchanges by themselves, at least not in the first few years. That shifted the responsibility to the federal government – and the disastrous rollout of the online portal on Oct. 1, 2013. Even after was repaired and working smoothly, most states (including some Democratic-governed states) stuck with, or shifted to, the federal exchange rather than running their own.

Yet while the legal and legislative battles raged, the law began to work – albeit imperfectly. By early 2014, the federal website and some of the states’ enrollment sites were much improved. The rollout in 2015 and 2016 went smoothly. Signups in 2017-18 were relatively stable (11.8 million signed up in 2018) given the adverse circumstances (and there are some early signs that enrollment might drop in 2019 but it’s too soon to know for sure.) Millions more are covered in Medicaid. Some people got covered enthusiastically, while others did so because their old plan was no longer an option or because they feared a penalty. The disaster scenarios – overcrowded hospitals, extremely long waits for health care, a collapsing financing system, and a job-killing effect on the overall economy – have not come to bear, although premiums for nonsubsidized people in the individual market have risen, in some states quite considerably.

Health care reform is sprawling and complex, with moving parts and unintended consequences. Health spending represents more than one-sixth of the economy - it neared $3.4 trillion in 2016  , and the rate of growth has ticked up. Health policy touches every individual, every family, every community. It is politically volatile, because it’s not only about health, or about money, but about the size and reach of government. How can we journalists cover a story with so many tentacles, so much misconception, so much rhetoric, so much jargon, so many statistics and so many acronyms (ACO, ACA, PCORI, IPAB, CMMI, MLR, AHBE, etc.) that our heads spin?

Perhaps the first thing to understand is that most of the political fighting was – and probably will remain – about the cost of covering millions more Americans and transforming parts of the health insurance industry. That’s a gargantuan task and it’s legitimate to ask questions about the costs and consequences of coverage, such as emergency room crowding, primary care shortages, basic benefits, subsidies for low-income groups, or affordability of insurance policies and health care itself.

But health care policy isn’t only about covering more people. The 2010 law touches on just about every aspect of health care. Delivery system reform (a clunky and confusing phrase that many of our readers and listeners may think pertains to the fate of Saturday mail service) is changing how Americans receive care, and how doctors and hospitals are paid for providing that care. It’s about doing a better job of managing and treating chronic disease, in a system that really has its roots in acute care circa 1960. It’s about aiming to ensure that people get quality care they need. It's about changing the culture and the payment incentives so that doctors and patients alike come to understand that newer, more expensive and higher-tech care isn’t always better than older, cheaper and less technical. It’s obscured by the Washington fights over coverage. But it’s deeply important and potentially transformative.

The U.S. system is a bizarre blend of undertreatment and overtreatment, a mélange of “the best care in the world” and a system rife with quality control, infection, complications and error rates that would not be countenanced in other settings. All of that is affected by health reform – no matter what shape it finally takes in the remaining years of the Trump era.


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