The Republicans have taken control of Congress, and with it ownership of health care reform. As long as the Republicans were in opposition, they could just complain. And they did, voting repeatedly — and futily — to repeal the Affordable Care Act.
Now, they are coming up with actual reform ideas. Their first reform proposal — to redefine full-time employment as 40 hours a week under the ACA — may be emblematic of what is to come.
The idea is favored by business groups that support the GOP financially. But such a change would increase the number of uninsured and raise the federal budget deficit by $53 billion over the next 10 years.
Currently, full-time employment is defined as 30 hours per week, and under the health care law, large companies must offer health insurance to those working full time. Most American workers now work close to 40 hours a week and are insured. But under the Republican proposal, employers could send employees home a half-hour early on Friday and drop their coverage.
The Congressional Budget Office estimates this change could “lead employers to make changes that would affect many more workers than will be affected under current law” as well as cause a million American workers to lose their employer-sponsored health insurance.
Nearly five years after its enactment, the ACA remains unpopular, despite the fact that many of its reforms — ending pre-existing condition exclusions, covering adult children to age 26, and closing the Medicare drug doughnut hole — are very popular.
The ACA has also been remarkably successful in achieving its goals. Both the percentage of Americans who are uninsured and the rate of growth in health care spending are at historic lows. Republicans continue to talk repeal, but actual repeal would at this point be disruptive.
One of the great virtues of the ACA is that it has managed to extend coverage significantly without disrupting the three primary forms of coverage enjoyed by most Americans. Nearly half of Americans are insured through their employment, while Medicare and Medicaid each cover another sixth. The ACA has expanded benefits for employed Americans by requiring coverage for preventive services and capping out-of-pocket expenditures. Employer-sponsored enrollment has remained largely stable under the ACA, while Medicare and Medicaid enrollment have grown. Premiums for employer coverage and for Medicare have increased more slowly than in previous years.
Republican reform proposals, on the other hand, take aim squarely at the most widespread forms of coverage. Conservatives have long called for an end to the tax exclusions that have helped to make employer coverage nearly universal in the United States. They would not eliminate them entirely, rather replacing provisions that currently exempt employer-sponsored coverage from income and payroll taxes with capped deductions and exclusions. For many employees this will result immediately in higher taxes or premiums. Moreover, Congress is unlikely to adjust the fixed dollar subsidies to keep pace with health care inflation, so excess cost increases will simply be shifted — dollar for dollar — to employees.
Republicans also have long proposed shifting Medicare to a premium support program. Seniors and the disabled would no longer be able to count on a guaranteed benefit, but would be given a fixed government contribution and have to shop for their own coverage. Republicans propose turning Medicaid into a block grant program, shifting to the states responsibility for bearing the increasing costs of the program.
One of the most problematic features of ACA coverage is the high deductibles and co-insurance that come with many marketplace plans for those whose incomes are too high to qualify them for cost-sharing reduction payments. But conservatives have supported high cost-sharing, and Republican proposals to repeal the ACA would wipe out the out-of-pocket expenditure caps it imposes. Republicans support generous tax subsidies for health savings accounts to help cover cost sharing, but HSAs only benefit those wealthy enough to put savings aside, and particularly those in high tax brackets.
Of course, any legislation that would undermine health coverage for Americans will have to survive a filibuster in the Senate and a veto from President Obama. Republicans believe they now have a trump card: King v. Burwell, the case the Supreme Court will decide this summer. Plaintiffs in King ask the court to read a few words of the ACA out of context to deprive millions of Americans of the help they are now receiving through the federal marketplaces.
Congress could easily clarify the meaning of these words through the kind of technical amendments that Congresses have always adopted after major legislation. ACA opponents, however, are encouraging Congress to use a potential adverse Supreme Court decision to push through much broader changes. Notice that Republicans are not promising if you like the coverage you have now you can keep it, whether you are covered by employer-sponsored coverage, Medicare or Medicaid.