Could Medicaid Expansion Remove the Threat of the ACA Repeal?

President Donald Trump has made repealing the Affordable Care Act (ACA) one of his top priorities. Fully repealing the health law is unlikely, however, in part because of the foreseeable filibuster by Senate Democrats. Meanwhile, budget reconciliation measures have already been implemented.

Repealing the ACA could have detrimental effects, not only for Americans who rely on the marketplaces for health insurance, but also may pose political risks for the Trump administration, according to a perspectives article published by The New England Journal of Medicine.

Adding further complications to GOP efforts to repeal the ACA is the growing public support for the legislation. Patients have increasingly voiced support for the law recently, and some governors are even writing certain ACA provisions into their own state laws.

While significant debate exists on where the ACA is effective, certain measures could be taken to preserve the law, and enroll more individuals in health plans.

More generous subsidies, increased penalties for remaining uninsured, fixing the risk-adjustment formula, and providing full coverage for the risk-corridor program are just a few methods lawmakers could implement to engage more health insurers in the marketplaces, and drive down costs, according to the article. However, it is unlikely that Republican lawmakers would implement these strategies, since it would add more government involvement.

A strategy that would likely gain support is to ensure that Medicaid managed care offers plans in which there would only be 1 other insurer in the ACA marketplaces. This method would provide health coverage even if subsidies are eliminated and replaced with another form of rebate, according to the study.

Medicaid is currently the most successful program that provides insurance, with more than 72 million individuals enrolled. This program keeps growing due to Medicaid expansion under the ACA, which shifts a large portion of the costs to the federal government.

States with expanded Medicaid programs typically have lowered uncompensated care received at hospitals, and can remove pressure from employers to provide coverage to low-wage individuals, according to the article.

Currently, 31 states plus the district of Columbia have expanded their Medicaid program, and dramatically decreased their respective uninsured rates.

Republican lawmakers argue that the instability of the ACA has made the law unsuccessful, which consequently increased costs. If the exchanges were kept, they would most likely stabilize over time, as insurers adjust their prices to better account for expected costs, according to the article.

However, with the Republican-controlled Congress taking aggressive actions to dismantle the ACA, the marketplaces will not have a chance to stabilize on their own. Crafting a replacement plan that promises insurance access to all Americans will take time, and require lawmakers to consider multiple options.

In some states, enrollees in expanded Medicaid were required to join through private exchange plans. This option may be supported by Republicans, since these individuals will be enrolled in private plans rather than traditional Medicaid, according to the article.

Relying on Medicaid as a safety net would be the best way to increase competition in states where only 1 insurer is selling plans on the exchanges, and reduce costs for enrollees.

Arizona has a successful Medicaid managed care program where enrollees in Pinal County can sign up with 1 of 5 Medicaid plans, since there is only 1 insurer selling plans in the ACA marketplace. This can serve as a model for expanding Medicaid on a national-level.

This option relies on the fact that Medicaid plans are the ideal fit for the marketplaces, compared with plans sold by commercial insurers, according to the article. Additionally, this option would not require lawmakers to create novel, experimental infrastructures that may or may not operate smoothly.

A barrier that may be faced is that not all Medicaid programs rely on capitated health plans, but instead use fee-for-service, or primary care case management. The states that use these programs could still be turned into safety-net back-ups through alternative methods.

Another barrier would be that exchange enrollees may be hesitant to sign up for a Medicaid plan due to varying performance reports and stigma associated with the program. On the other hand, with millions of enrollees, Medicaid is becoming more accepted, and the program has evolved to understand sufficient provider capacity, according to the article.

Republican lawmakers may push back against this option since it would keep the ACA in place, and expand Medicaid even further. A plus for these lawmakers would be that additional plans offered by Medicaid would be from private insurers. Despite potential criticism, Trump promising insurance to all through Medicaid would likely be the easiest approach, the article concluded.