October 22, 2020
Since its enactment in 2010, the Affordable Care Act (ACA) has become a symbol of the extraordinary political polarization in the United States. Republicans have failed to repeal or replace the legislation, while Democrats have been unable to build on the ACA, resulting in a stalemate in Congress. Now, with a presidential election only weeks away and COVID-19 cases rising, health care policy is once again at the forefront of American minds.
The outcome of the election on Nov. 3 could be vital for the future of the ACA, according to a new ‘Perspective’ published today in the New England Journal of Medicine. It is co-authored by Jonathan Oberlander, PhD, professor of health policy and management at the UNC Gillings School of Global Public Health and chair and professor of Social Medicine in the UNC School of Medicine. Oberlander has spent the past decade exploring the ACA and analyzing how its evolution has shaped the landscape of American politics.
Oberlander notes that “the ACA’s political trajectory is not what its architects anticipated. Rather than attracting bipartisan support, Obamacare remains an object of intense partisan struggle.”
Should the Republican party win both the White House and Congress, it might attempt a repeal. But the consumer protections, coverage expansion and insurance regulations built into the ACA have wide public support, and with no policy alternative defined, a repeal attempt could backfire for Republicans as it did in 2017. The party may run into less resistance by taking a piecemeal approach to dismantling the Act, repealing parts that are unpopular with their constituencies, such as the penalties on employers for not offering insurance. According to the authors, Republicans might also work to encourage state-level restrictions on Medicaid eligibility.
In contrast, a Democratic win in the White House and Congress could create a favorable environment for improving ACA eligibility by strengthening protections, increasing subsidies for Americans that make insurance more affordable, and eliminating gaps in coverage for low-income persons who live in states that have not expanded Medicaid. Democrats could also pursue plans to expand eligibility to Medicare to persons age 60-64 and establish a new public insurance option open to those who are uninsured and already insured. There is strong public support for a public option. However, as Oberlander has previously discussed, there is disagreement over what a public option actually means as well as major obstacles to enacting such a plan in Congress.
The recent death of Supreme Court Justice Ruth Bader Ginsberg introduces more uncertainty into the fate of the ACA. The authors note that a potential Supreme Court decision to strike down the ACA or any of its major components would destabilize both the insurance market and health politics.
“A breakthrough in health policy is not inevitable during the next administration,” Oberlander and co-authors wrote. “Still, the profound political and economic instability wrought by COVID-19, frustrations with the ACA’s limitations, the legal uncertainty and a polarized environment in which parties are willing to legislate without bipartisan support mean that major change is possible.”
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