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State of the Nation in U.S. Healthcare: What Has Changed for 2018?

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.

By Suzanne Discenza
January 22, 2018

[This article is first in a series of quarterly columns exploring the state of U.S. health care and health policy in the nation, the states, local governments, and nonprofits.]

One short year ago, with inauguration of a new President and more conservative Congressional control, American citizens were pondering the future of not only the Patient Protection and Affordable Care Act of 2010 (also known as the ACA or “Obamacare”), but also of many other important public health policies and programs across the U.S. Would the ACA be “repealed and replaced,” as promised by the new administration? Would elimination of Medicaid expansion or reduction in Medicaid services again leave more of the country’s poorest citizens with no access to healthcare beyond high-cost emergency department use? What would happen to the 20 million people insured through state health insurance exchanges if Congress repealed the ACA? Would Medicare “entitlements” be privatized or replaced by “vouchers,” with a fixed dollar amount being provided to each Medicare recipient regardless of the costs of their medical needs?

By all apparent measures of relative time, federal health policy changes during the past 12 months would appear on the surface to be relatively minor and/or inconsequential as compared with the sweeping changes instituted during the prior decade when more Americans began receiving “more affordable” access to healthcare services with passage and implementation of the ACA. Yet the more historically U.S. approach to policy change, referred to by scholars as incrementalism, has again reared its head in national U.S. policymaking. Defined as the “cautious style of decision making in which changes are implemented gradually or in small steps,” incremental health policy changes in the U.S. resulted not in sweeping repeal by Congress of the Affordable Care Act or the state Medicaid Expansion option, but rather in Congressional and Presidential efforts to begin “chipping away” at previously-mandated individual policies and programs within those larger pieces of legislation.

What Happened to Repeal and Replacement of the ACA?

 The promise to “repeal and replace Obamacare” by the new U.S. administration and Republican-controlled Congress in 2017 met with significant obstacles and resistance by not only Congressional Democrats but also by the majority of U.S. voters, who staged protests in the nation’s capitol, in many major U.S. cities, and within, or in front of, the offices of many elected U.S. Senators and U.S. House Representatives. According to an Associated Press-NORC Center for Public Affairs Research survey released on July 19, 2017, just 13 percent of voters supported the U.S. Senate plan to replace the ACA without an acceptable replacement, supported by a June 2017 USA TODAY/Suffolk University poll showing only 12 percent of Americans supporting the Senate Republican healthcare plan.

Yet without the willingness of a few U.S. Senate Republicans to cross party lines to vote against the repeal of ACA legislation, repeal without replacement would have been the new law of the land. In a historic vote on July 28, 2017, the U.S. Senate narrowly rejected by a 51-49 margin a third Republican proposal to repeal the ACA, including a “skinny” repeal amendment called the Health Care Freedom Act, with Senators John McCain of Arizona, Susan Collins of Maine and Lisa Murkowski of Alaska casting the negative Republican votes. On September 26, 2017, Senate Republicans admitted they did not have the votes to support a renewed effort to repeal ACA legislation.

Incremental Efforts to Diminish Pieces of ACA Legislation

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While U.S. Congressional Republicans and the Trump administration failed to fully repeal the Affordable Care Act outright, it goes without saying that efforts to score legislative victories for the Republican Party, including for ratcheting down portions of the Affordable Care Act, have remained ever on the Republican Congressional legislative agenda. One of the most significant of these “wins” included passage by the U.S. Senate of a sweeping GOP Tax Plan on December 2, 2017, by a 51-49 vote, mostly along party lines (with the exception of Tennessee Republican Senator Bob Corker). A significant part of this legislation that specifically targeted a provision of the ACA was repeal of the Individual Mandate, requiring all U.S. citizens to enroll in health plans or risk incurring financial penalties for not doing so. The financial impacts of this legislation remain to be seen due to its recent passage.

A second even more recent effort to decrease support for provisions of the ACA involves the January 18, 2018, announcement by the Trump administration allowing U.S. states for the first time to “move toward imposing work or job training requirements on people as a condition for obtaining health insurance under the government Medicaid program for the poor,” according to Reuters.  A January 11 article in the New York Times noted U.S. officials would also support state efforts in requiring “able-bodied adults to work or participate in ‘other community engagement activities’,” such as education, care giving or volunteer activities, to maintain Medicaid eligibility.

Part II of this series will specifically highlight health policy initiatives by states in 2018.

Author: Dr. Suzanne Discenza is a Professor (Ret.) and Past Director of the MHA Program at Park University, and continues to teach online in Public Administration. She completed her Ph.D. in Public Affairs at the University of Colorado. Current District IV Representative to ASPA National Council, she is a Past Chair of the Section for Women (SWPA) and of the Health Policy Forum for AUPHA.


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