Three legs support a stool. Cut one leg off, and the stool falls. The Republican Party has continuously attempted to cut off the “subsidy leg” from the Affordable Care Act (ACA). By dismantling part of a necessarily interconnected plan, they threaten financially feasible health coverage for millions of Americans.
The ACA can only function if the following three policies are implemented together: 1) giving Americans with pre-existing medical conditions access to health insurance, 2) mandating insurance coverage, and 3) providing subsidies. By undermining even one of these, the ACA collapses. Thus far, these policies have delivered results in meaningful ways. Since 2013 the uninsured population has dropped by almost 25 percent (about 8-11 million people). Long-standing insurance fairness issues have also been resolved.
Are there problems? Absolutely. Healthcare.gov rollout glitches frustrated many. Some patients face increasing deductibles and copays, limiting care for some covered individuals. Single adults with medium-low income are stuck in a “coverage gap” in many states, because they can neither afford private plans in the exchanges nor qualify for Medicaid or subsidies.
Despite the setbacks, two things are clear: the policies of the ACA are a step in the right direction—toward insuring all Americans—and the law is here to stay.
In 2012, the Supreme Court upheld the ACA in the landmark case National Federation of Independent Business v. Sebeilus. This was not without collateral damage to the law; mandatory Medicaid expansion was struck down, allowing states to opt out, denying coverage expansion. Nevertheless, the “mandate leg” was upheld. All three branches of government have endorsed the constitutionality of the ACA. Yet, Republicans still refuse to accept the law.
Republicans recently swept the midterm elections and gained Congressional majorities in both the House and Senate. With such momentum behind them, Rep John Boehner (R) and Sen Mitch McConnell (R) announced they are “renewing our commitment to repeal ObamaCare, which is hurting the job market along with Americans’ health care.” This statement is irresponsible governing, goes against evidence, and states aims that are practically and politically impossible. President Obama will veto any bill threatening his crowning achievement, and Republicans have insufficient numbers in Congress to overrule his veto.
In fact, Republican states have benefited greatly from the ACA, both in terms of insurance coverage and financial gains. Medicaid expansion has been achieved in 26 states (seven governed by Republicans) and the District of Columbia as of December 2014. These states have experienced greater drops in uninsured patients, compared with states denying expansion (23 states, 20 of which are governed by Republicans). Furthermore, at the county level, Republican counties have experienced greater drops in un-insurance compared to Democratic counties. Yet, a November 2014 PEW research poll showed that 88 percent of Republicans support repealing Obamacare.
Do politics align with policy? No. In fact the politics don’t even align with common sense in this case.
On the judiciary front, the Supreme Court recently took up King v. Burwell, which debates ACA language specifying that state exchanges may distribute tax credit subsidies, but federal exchanges cannot. Despite the lack of a split decision in the lower courts, four conservative Justices have opted to take on the case. Unsurprisingly, Republican leaders issued a brief in September to encourage the Court to take on this case. To understand this absurdity, let’s examine one of the authors, Senator Ted Cruz of Texas. His state uses a federally run exchange where almost 600,000 people are eligible to purchase insurance, of which 200,000 have enrolled into a plan. By arguing over a legislative typo, Senator Cruz may cause diligent constituents to lose their newly acquired insurance.
Most recently, House Republicans filed a lawsuit against the President Obama, arguing that the executive branch cannot force Congress to appropriate and distribute subsidies to Americans. This is yet another attack on the ACA’s “subsidy leg.”
The dual mission of covering Americans and controlling the soaring costs of healthcare was at the heart of healthcare reform. The law of the land requires an integrated, multifaceted approach. The political players must learn to grapple with the three key changes that need to happen simultaneously in order for financially feasible insurance coverage expansion to take place in this country.
Democrats and President Obama have thus far succeeded in the policy battle, but are on the defensive politically. Republicans have used every opportunity to unseat patients from the three-legged stool of the ACA. Most recently, they have taken aim to cut down the “subsidy leg,” by undermining Medicaid and supporting the recent Supreme Court challenge.
Three legs support a stool. Keep all legs up, and the stool stands.
Sumit R. Kumar is a M.D., M.P.A. candidate at NYU. He is pursuing a career in Internal Medicine. Follow Sumit on Twitter. The views expressed herein are those of the author and do not necessarily reflect the views of NYU or any other entity.