With the 2024 election less than two months away, it is becoming increasingly clear that healthcare system reform (e.g. “Medicare for All”) will not be as prominent of a topic as it has been in past elections. This was further reinforced during the Presidential debate on September 10^th which did not have a heavy focus on healthcare issues outside of reproductive rights. The one debate topic that did receive some attention was the candidate’s views on the Affordable Care Act (ACA). Perhaps more time should have been spent on this topic since the future of the ACA will be one of the most important issues the election winner will have to address during their term.

The ACA remains polarizing but opposition has gradually toned down compared to the strong “repeal and replace” rhetoric after the bill was passed in 2010. Despite critics’ desire to repeal and replace the ACA, that is not legislatively possible without either 60 votes in the Senate or by the Senate changing its rules (specifically, Rule XXII) to lower the threshold for cloture votes from three-fifths (60 votes) to a simple majority.

In 2017, President Trump and House and Senate Republicans attempted to drastically alter the ACA. Lacking 60 Senate votes but controlling both Chambers of Congress, Republicans used the Budget Reconciliation process, a commonly used legislative procedure that allows legislation to bypass the Senate’s 60-vote threshold. Budget Reconciliation bills are limited in that they can only include policies that impact federal spending or revenue. For example, Budget Reconciliation bills cannot repeal the ACA’s individual mandate language. However, they can lower the individual mandate’s penalty to $0 – which Republicans eventually did in a different reconciliation bill.

The 2017 repeal effort failed partially for political reasons but also because some Senators were unhappy with the replacement part of the effort. However, the Trump Administration still took many actions that impacted the ACA.

Some of the chief criticisms of the ACA are that the plans are too expensive for consumers and that the federal government is subsidizing these plans at a huge cost to taxpayers – $1.1 trillion in 2023 according to the Congressional Budget Office (CBO).

Therefore, the Trump Administration took many regulatory and executive actions to make alternative forms of health insurance more accessible to consumers. These alternatives included Association Health Plans (AHPs) and Short-Term Limited Duration Health Insurance (STLDI) plans. AHPs allowed organizations to form group purchasing networks to purchase health insurance. These collectives would have more negotiating leverage with health plans than each individual member. STLDIs are only intended for short coverage periods of only a few months. They have high-deductibles that reset after every coverage period. The Trump Administration expanded the duration of these plans to one year to make them more competitive with ACA plans.

The Trump Administration also emphasized high-deductible health plans (HDHPs) linked to health savings accounts (HSAs). As the name suggests, these plans had higher individual cost sharing but also lower premiums. Enrollees would spend more of their money on care that was actually provided instead of spending it on monthly premiums that are not tied to how much care an individual receives.

The AHP and STLDI expansions did not have much of a chance to get off the ground before the Biden Administration quickly rescinded them. In fact, this week, the House Education and Workforce Committee passed a resolution (along party lines) opposing the Biden Administration’s effort to rescind the AHP regulations. This resolution could allow a future Congress to use the Congressional Review Act (CRA) to overturn these regulatory actions to rescind the AHP rules.

Notably, Democrats never reversed the Republican’s legislation to eliminate the individual mandate penalty, which remans at $0. This allowed for some legal challenges to the ACA which ultimately did not succeed. The ACA’s authors feared that without a mandate, savvy consumers would wait until they were sick to enroll in a plan which would skew actuarial calculations.

Interestingly, ACA enrollment has remained at record highs despite no penalty for having no insurance. Perhaps this is largely due to the fact that President Biden and Congressional Democrats passed a huge expansion of ACA subsidies.

The ACA limits eligibility for premium assistance subsidies to people earning up to 400% of the federal poverty level. The American Rescue Plan Act (ARPA) of 2021 and the Inflation Reduction Act (IRA) temporarily eliminated the income eligibility cap. This means that anyone was eligible for ACA premium assistance regardless of their income level. The new subsidy formula would be based on limiting premiums to a percentage of someone’s total income.

This eligibility expansion expires after 2025. This means that the next President and Congress will need to decide if this policy should be extended or ended. Allowing the policy to end would likely result in a large enrollment decline.

Adding to the importance of this decision, a separate policy is requiring states to revalidate enrollment eligibility for every Medicaid beneficiary by the end of 2025. This policy could similarly lead to more consumers losing Medicaid coverage. While these people will be eligible for ACA coverage, it is unclear how many of them will enroll in an ACA plan.

During presidential campaigns, we are used to hearing candidates talk more about reforming healthcare. For Democrats, proposals include dramatic reshaping of our healthcare system such as government-run “single payer” and “Medicare-for-All.” However, if one looks beyond the campaign rhetoric and examines the current policy landscape, it is clear that the conversation is not about “Medicare for All.” The real question is should we continue “ACA for All.”

With no income eligibility limit, the ACA is currently available to everyone (who does not otherwise have access to insurance provided by the government or their employer). The ACA, like Medicare, is a version of government subsidized health insurance. These concepts accomplish similar goals albeit in very different ways.

In 2025, we will see Congress and the new President grapple with the ACA once again. Will we see Democrats extend the Biden Administration’s ACA subsidy expansions? Will Republicans revive their ACA alternatives?

With neither party expected to win 60 votes in the Senate, little can be done on any of these questions, especially if there is a divided government.

An audit of the Pennsylvania Medicaid Program revealed $7 million in excess spending on prescription drug benefits in 2022. The report points to PBM’s hidden fees and spread pricing as the key factors that increased costs, calling for legislative reforms to increase transparency and improve accountability in order to prevent overspending.

On Friday, September 6, CMS revealed that 946,801 Medicare beneficiaries may have had their personal information exposed in a data breach involving third-party software used by its contractor, Wisconsin Physician Service Insurance Corporation (WPS). The breach was linked to a security flaw in MOVEit software, exposing sensitive data including social security numbers and Medicare Beneficiary Identifiers.

The Federal Trade Commission stated that it is mandating refunds totaling more than $49,500 for over 2,400 consumers as part of a settlement with 1Health.io. The settlement addresses claims that the company failed to secure sensitive data and misled consumers about their ability to delete their information.

Data from the U.S. Census Bureau shows that health insurance rates remained steady in 2023, with no overall change in uninsured or public and private coverage. However, there were some shifts within specific types of insurance, including increases in Medicare coverage and decreases in Employment-based insurance.

On Tuesday, September 10, the Senate passed the CBO Data Sharing Act, which allows the Congressional Budget Office (CBO) to access sensitive health care data without extensive delays. The bill aims to help the CBO improve the speed and accuracy of its analyses on health care proposals.

The House Education & the Workforce Committee advanced the Transparent Telehealth Bills Act on Wednesday, September 11. The goal of the bill is to prevent extra facility fees for telehealth services as an effort to lower health care costs and protect telehealth consumers

Yesterday a bipartisan group of House members introduced the “No Surprises Act Enforcement Act.” According to the associated press release, this legislation reforms the No Surprises Act by “closing enforcement gaps through increased penalties for non-compliance of statutory payment deadlines, providing parity between penalties imposed against parties non-compliant with statutory patient protection provisions, and Increasing transparency in reporting requirements”.