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When to get nervous about the ACA

Posted by John McDonough  July 11, 2013 11:41 PM

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Last week's decision by the Obama Administration to delay for one-year the implementation of the employer responsibility (aka: employer mandate) provision of the ACA drew a predictable and surprising partisan divide. Republicans, who always opposed requirements on employers, attacked the Administration for delaying something they despise (surprise), and used the delay to suggest that the ACA is falling apart. Democrats, who always supported employer responsibility, dismissed the delay as no big deal, and claimed ACA is largely on track.

The question has been raised -- what would constitute an alarming and dangerous delay in the eyes of ACA supporters?

Delay in any of these five provisions -- all scheduled for implementation on January 1 2014 -- and I will agree it's time to be concerned:

greek-chorus.jpg1. The insurance market reforms, especially guaranteed issue, banning medical underwriting and the imposition of pre-existing condition exclusions;
2. The individual responsibility provisions (aka: the individual mandate);
3. The health insurance premium and cost sharing subsidies and tax credits;
4. The opening of the state/federal health insurance exchanges/marketplaces;
5. Implementation of the Medicaid expansions in states that opt to expand.

Any of those get delayed or postponed -- count me among the worrywarts. Nearly everything else? Not central and not fatal, if postponed.

By now, we understand that whenever there is any middling or negative news about the ACA, Republicans become a Greek chorus of wailing and gnashing of teeth. That's all they can do. And they have nothing to offer as an alternative.

Today, House Speaker John Boehner, arguably the least effective leader of that institution in the last 100 years, announced that the House would take up legislation to delay the ACA's requirements that individuals also purchase coverage -- because opposition to Obamacare is apparently the only thing left on which House Republicans can agree. Since the early 1990s, Republicans promoted a tough  individual mandate, and demanded individual responsibility with no employer responsibility at all. Now they they've got -- albeit for one year -- and they are determined to attack Democrats for something they once advocated with passion.

"The irony of objecting to the delay of a program you've been trying to stop is no doubt lost on this room," observed Rep. Jim McDermott (Wash.), the ranking Democrat on the subcommittee, caught by Dana Milbank in yesterday's Washington Post.

But Republicans have a problem, even with this. Eliminating an individual mandate without also eliminating the provisions against pre-existing conditions guarantees major insurance premium hikes, far beyond anything seen thus far. If Republicans want to delay the mandate, do they also propose delaying the elimination of pre-existing condition exclusions which are strongly supported by the public? No word. Undoubtedly, they haven't thought of that because they know their proposal will go nowhere, regardless of what the House does.

The news involving the ACA, by the way, is not all bad. Yesterday, it was announced that the nation's biggest drugstore chain, Walgreens, will join the Blue Cross Blue Shield Association to educate consumers about new insurance coverage options in the ACA. The Blue Cross Association, by the way, was hostile to the ACA during the legislative process, and many of its members spent large sums of money to try and kill it. Guess that's changed now.

There's more. Nearly 1,200 federally qualified community health centers will be using $150 million in federal support to enroll their uninsured clients in coverage. In Massachusetts in 2006 and 2007, health centers played a vital role in the successful enrollment of uninsured citizens in the new coverage options. The Congressional Black Caucus is also getting into the cause, planning a national series of events to publicize the law among communities with large numbers of potential enrollees.

While there are ups and downs with ACA implementation, the increasing volume of cries from ACA opponents is a sign of their fear more than anything else.  They realize they cannot stop ACA implementation. It's going to happen in spite of their determined efforts to kill it. The louder they yell, the more we should realize, they are not worried about the law or the impact on real people.  They are worried about themselves. And they should be.

This blog is not written or edited by Boston.com or the Boston Globe.
The author is solely responsible for the content.

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About the author

John E. McDonough is a professor of practice at the Harvard School of Public Health. He is the author of the book “Inside National Health Reform”, published in 2011 by More »

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