Uncertainty has plagued the health care marketplace in the past few years. The election of Donald Trump in 2016 meant the future of Obamacare would remain unclear, and repeated efforts by Republicans to repeal the health care law have fueled this uncertainty.
Democrats’ success in the 2018 midterm elections means they now control the House of Representatives, and this shift was seen as a sign that the ACA would remain the law of the land — although a surprise court ruling in mid-December revived questions about its constitutionality.
The new ruling certainly doesn’t calm the waters, but it also doesn’t automatically mean the end of the line for the Affordable Care Act, says Ernie Sweat, a senior consultant at Fringe Benefit Analysts. “This is the opinion of one district judge,” and appeals will be heard by other judges and very likely the Supreme Court, he says.
In the meantime, the ruling does not block the operation of the law, as was requested in the lawsuit, Sweat says. The most likely path forward — for the moment — is status quo.
But what does the situation mean for health care policy in 2019? With a new Congress and this new ruling, employers are left wondering about health care policy planning for this year and beyond.
Here’s what you need to know.
While the Dec. 14 ruling raises a new round of questions about the ACA’s legal status, many observers continue to feel the law is here to stay, and that the focus going forward should be on modifications to tackle health care costs. “The salience of the issue of health care in the midterms might trigger some bipartisan efforts, including looking at efforts to stabilize the marketplaces,” says Sara Collins, vice president of health care coverage and access at the Commonwealth Fund.
Sweat says the new Congress looks likely to focus on bipartisan legislation aimed at addressing issues with the law. “There seems to be agreement on both sides of the aisle that there are some problems with the Affordable Care Act,” Sweat says.
Collins says one area of likely focus will be to ensure that everyone has access to a competitive plan. “There are a few bills in Congress that would add a public plan based on Medicare to the marketplaces, so in states or markets where there are very few plans being offered, adding a public plan option to those markets might give some people more choice and increase price competition,” she says.
This could have a positive effect on employers and employees by giving them the option to enroll in a public plan. “But the key thing is making sure people have access to a plan in a competitive market,” Collins says.
The success of Medicaid expansion efforts in Idaho, Nebraska and Utah in 2018 means about 360,000 individuals will gain access to health coverage. Maine voters previously were the first to agree to expand Medicaid access, in a 2017 ballot question. “It was a Medicaid wave in terms of the outcomes on three ballot initiatives at least in Maine, Idaho, Nebraska and Utah,” Collins says.
This expansion will have a positive effect on the overall health of the system, she says. “First of all, it's just important to have people covered, and it certainly will help the bottom lines of health care institutions, where people get their care,” Collins says. “It encourages people to get the care they need, but it also makes it financially feasible for institutions, particular safety net institutions.”
Sweat says Medicaid expansion is integral to the success of the ACA and its intended effect on the health care marketplace. “The Affordable Care Act, the rules about individuals who qualify for subsidies and who do not, does not work without Medicaid expansion,” he says.
He says that other states that have previously not expanded Medicaid are more likely to do so. “I believe that over time all the states in the country will be on board,” Sweat says.
Given the importance of health care with voters in the midterms, Collins says, we’re likely to see proposals to improve access to coverage and to control costs as the 2020 election approaches. “We might see tweaks to the Affordable Care Act, a range of options that would add a public plan to the marketplaces or bills that would open Medicare for buy-in for people over a certain age but under age 65,” Collins says.
The issue of “Medicare for all” and a more universal approach to health coverage will be part of Democrats’ agenda for 2019, Collins says. But the most likely result will be incremental improvements; sweeping change is very unlikely, she says.
Democratic control of the House also means a likely rise in oversight. “We've seen a lot of rules and new guidance from the Trump administration that we will likely see [come under scrutiny with] oversight hearings in the House,” Collins says.