What the Election Could Mean for Obamacare

Note: This transcript has been created with a combination of machine ears and human eyes. There may be small differences between this document and the audio version, which is one of many reasons we encourage you to listen to the episode!

Dan Gorenstein (DG): The fate of the Affordable Care Act has played a leading role in presidential elections for more than a decade. This cycle, it’s different. Apart from a few cameos, the 14-year old law — sometimes called Obamacare — has been largely off-stage as immigration, the economy and democracy dominate the fight between Vice President Kamala Harris and former President Donald Trump. But in the final days of the race, the ACA is back.

House Speaker Mike Johnson: Health care reform’s going to be a big part of the agenda. When I say we’re going to have a very aggressive first 100 days agenda, we got a lot of things still on the table.

DG: At a campaign stop in Pennsylvania this week, House Speaker Mike Johnson told a crowd that “massive reform” is needed. Harris, in a major speech in DC Tuesday night, warned the crowd about a future without Obamacare.

Vice President Kamala Harris: You will pay even more if Donald Trump finally gets his way and repeals the Affordable Care Act – which would throw millions of Americans off their health insurance. And take us back to when insurance companies had the power to deny people with preexisting conditions.

DG: Today, the Affordable Care Act, its track record, and what Republican reform could look like. From the studio at the Leonard Davis Institute, at the University of Pennsylvania, I’m Dan Gorenstein and this is Tradeoffs.

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DG: The ACA has been a fact of life for long enough now that it can be easy to forget how much it changed how Americans get their health insurance. To remind us of the law’s impact and what possible changes could mean, we called up one of the nation’s leading Obamacare experts.

Larry Levitt: I’m Larry Levitt, executive vice president for health policy at KFF.

DG: KFF is a nonpartisan health policy research organization, and the group as well as Larry have been studying the ACA since before its inception.

Larry, inasmuch as we’re here to talk about the ACA’s track record, there are three key components that, at least to me, seem worth highlighting. And let’s go through these one by one. First, the law required health insurers to cover people with pre-existing conditions. What impact has that had?

LL: Well, the impact has been tremendous. If you had a preexisting condition before the Affordable Care Act — a cancer diagnosis, multiple sclerosis, being pregnant, being overweight — if you tried to buy insurance on your own, you would be denied. If it was a mild preexisting condition, you might be offered health insurance, but have to pay a higher premium or have benefits associated with your health condition excluded from your coverage. So the ACA was a sea change. Insurance companies have to provide coverage regardless of your health. They can’t charge you a higher premium if you’re sick. And there are a set of essential benefits that all insurance companies have to provide.

DG: Is there one number that jumps out at you, Larry, as it pertains to coverage for people with preexisting conditions?

LL: So the number that jumps out at me is over a quarter of adults under age 65 have a preexisting condition that would have led to a denial of insurance before the ACA. So this is not something that affects a small number of people. This is something that is is quite pervasive.

DG: Here’s the second key component to the ACA that I think we need to highlight. Before Obamacare, if you could not get insurance through work. You had very few options to get coverage. Can you talk about those times? What’s changed?

LL: So the federal government now under the ACA provides a tax credit that covers a portion of the premium, in some cases, the whole premium for people who are very low income. And this is important. I mean, protecting people, getting people coverage, including people with pre-existing conditions, is not just about rules for insurance companies. People have to be able to afford the coverage. And it’s very expensive. I mean, health insurance for a family now costs what it would cost to buy a car. It’s extremely expensive to get health insurance in this country. And for the vast majority of people, without the federal help to pay a portion of the premium, they simply couldn’t afford coverage.

DG: Finally, Larry, Obamacare expanded Medicaid and all of a sudden, states could allow people making up to 138% of the federal poverty level sign up for Medicaid. That’s about $43,000 for a family of four. I’m going to ask you for super short answers here. How many people have insurance now because of Medicaid expansion?

LL: 20 million people now have coverage because of the Medicaid expansion.

DG: What do we know about the health benefits of Medicaid expansion? Are people any healthier because of this coverage, particularly this population?

LL: There’s a huge literature now on the effects of of Medicaid expansion, that it improves health, improves financial security, and improves state finances and economies.

DG: When you put it all together, Larry, the Affordable Care Act was an effort to shrink the number of Americans who were uninsured. I know it’s complicated to say exactly how many more people have coverage now than would’ve in a world without the ACA, but at a high level, how many people today have insurance because of the Affordable Care Act across the board?

LL: About 45 million people now have coverage through the ACA, whether that’s the Medicaid expansion or the premium assistance that helps people buy coverage. The ACA cut the uninsured rate by more than half. That said, there are still over 25 million people who don’t have health insurance. Many of them are eligible for Medicaid or the ACA, and may not know it or may not feel they can afford it. But the ACA has gotten us as close to universal coverage as we’ve ever been.

DG: When we come back, Larry explains what kind of changes Republicans could make to the ACA, and what those changes would mean for our health insurance.

Break

DG: Welcome back. We’re talking today with KFF’s Larry Levitt about the Affordable Care Act and how it could change if Republicans sweep to power in this year’s election.

Now, critics of Obamacare have raised concerns that the law’s subsidies have led to fraud. For listeners who are interested, you can check out last week’s episode to know more about that. Also, though, as you know, Larry, critics have talked about the quality of coverage, saying that that is worse, and the cost of premiums and deductibles are higher. What does the evidence say about those critiques?

LL: So I’ll start with what has happened to premiums. And it is true. When the ACA went into effect, premiums for individual health insurance, health insurance you buy on your own, went up. That’s because insurers had to provide coverage for preexisting conditions, had to provide certain essential required benefits, and that costs money.

DG: They had to cover more stuff.

LL: They had to cover more stuff. They had to cover mental health, they had to cover maternity. They had to cover substance abuse treatment. All of that costs money. So premiums went up. Now, the premiums that people pay out of their own pockets went down. And that’s because of the subsidies the federal government is providing to help people pay for their health care.

DG: And what about quality? Is there any evidence that health insurance is worse as a result of Obamacare?

LL: The quality of coverage has, I think, largely gone up. The benefits, the stuff that insurance companies have to provide is now more comprehensive. It covers preexisting conditions. It covers all of these required benefits. Now, health insurance under the Affordable Care Act, health insurance generally is still far from perfect. Networks, the doctors and hospitals that insurers cover are often quite narrow. It can be hard to get an appointment. That’s not true just under the ACA. It’s true for people who get insurance through their employer as well. I don’t think you can pin this on the ACA, but no, the health insurance is certainly not perfect.

DG: Earlier this week, Republican House speaker Mike Johnson said Congress would pursue “massive reform” of the ACA if Republicans sweep Congress and the White House. Former President Trump has said in the debate with Vice President Harris that he has “concepts of a plan” on health reform. We have yet to see anything concrete from Republicans. You have your ear to the ground, of course. Can you walk us through some of the ideas that conservatives are at least talking about? The things that they might do?

LL: Yeah. So there are a few different ideas out there. And we saw some of this in the comments by Republican vice presidential candidate Vance creating high risk pools for people with preexisting conditions, or creating separate pools for people who are sick and people who are healthy. And if we look back at President Trump’s presidency, his budgets proposed converting both the Affordable Care Act and Medicaid into a block grant to states, meaning removing federal rules and giving states a lump sum of money and giving states flexibility in how to use that money. We’ve seen similar plans, for example, from a group of conservative Republicans in the House which would also convert Medicaid in the ACA into a block grant to states, remove federal protections in the insurance market, and cut federal spending by $4.5 trillion over a decade. So the playbooks are out there for what massive health reform might look like from a Republican perspective.

DG: One other likely change that Republicans could make to the ACA, which we also talked about in last week’s episode, was letting Obamacare’s so-called enhanced subsidies expire at the end of 2025. KFF data shows that would raise premium payments for consumers significantly, and government analysts estimate about 3 and a half million people would lose coverage. I remember there are also a handful of policy ideas that President Trump pushed in his first term and conservative thinkers still talk about. Things like limited-duration health insurance, association health plans, Farm Bureau health plans. My memory is that these were all types of insurance that would cost less and cover less than an Obamacare plan. Is that right?

LL: Yeah, I hate to fall back on the name of your podcast, but these ideas all have tradeoffs. The ACA required coverage for preexisting conditions, required mandated benefits. That all costs money. And that raised premiums, particularly for younger and healthier people. These ideas like segregating risk pools, association health plans have tradeoffs in the other direction. People who are young and healthy could get cheaper insurance, but people who are older and sicker would end up paying more.

DG: And look, I remember when I first started talking to you about this law, in 2012, 2013, a lot of people really did not like the Affordable Care Act. There was a lot of fear over what the ACA would do to them, what it would mean for their lives and their health. As we know now, attempts by Republicans to overhaul the law seemed to backfire politically over these last few elections. What’s the popularity of the ACA today? You guys at KFF do plenty of polling. What do we know about how attitudes have evolved?

LL: Yeah, we’ve been polling for now more than a decade and a half about the ACA. And you’re absolutely right. When the ACA was being debated after it passed, it was quite controversial. That changed when Republicans tried to repeal and replace it in 2017. For the first time, the ACA was clearly more popular than not and has grown more popular since then. Now, 62% of the public views the ACA favorably. That’s dramatically different than when over half the public viewed it unfavorably.

DG: Why do you think that’s changed?

LL: The Republican efforts to repeal and replace the ACA were quite controversial. One thing Republicans succeeded in doing in 2017 was repealing the individual mandate penalty, the penalty for not having health insurance. That was by far the most unpopular part of the law and getting rid of it, I think, made people more comfortable. And it’s now over a decade since the ACA’s main provisions went into effect, and more and more people have benefited from the law.

DG: Final question. You have followed the politics and the policy of this closer than most people in our country. With less than a week to go before the election, what do you think the stakes are for the ACA right now? How do you assess this moment from a ACA health policy perspective?

LL: If Republicans sweep this election, I think the ACA, along with Medicaid, will have big targets on their back. If Harris wins or Democrats are able to hold on to one House in Congress, I think the ACA will be safe. And even though the ACA has not been a big topic in this campaign, it is still a fork in the road election for the future of the law.

DG: Larry, thanks for taking the time to talk to us on Tradeoffs. 

LL: Thank you.

DG: I’m Dan Gorenstein, this is Tradeoffs.