The ACA is safe for now, but it’s still very much in danger

Yesterday, House Republicans failed to find enough votes to pass their Affordable Care Act replacement. It was a very good day for the millions of Americans projected to lose their coverage under the GOP plan. But let’s be clear: Obamacare is not safe.

In a last-ditch effort to round up more votes, House Speaker Paul Ryan, R-Wis., proposed an amendment that would have, beginning in 2018, allowed states to determine the kinds of essential health benefits required in insurance plans purchased with tax credits. Under Obama’s health care law, insurance plans sold via the federal health care marketplace had to cover 10 essential health benefits, as did coverage via the Medicaid expansion. Those 10 benefits are: outpatient care; emergency room care; in-hospital care; pregnancy, maternity and newborn care; mental health and substance abuse; prescription drugs; rehabilitative and habilitative services; lab tests; preventive services; and pediatric services. This is basic health care coverage that provides actual value for your dollars. Fortunately, for those of us who’d prefer real value in their insurance plans and who realize there’s no such thing as a functional a la carte health insurance market, the Republican plan failed.

However, it’s not only Congress that can impact the essential health benefits. In fact, federal officials can do all kinds of things through the regulatory system to impact the ACA, including doing nothing at all. The ACA isn’t perfect — few pieces of legislation are — and without federal support to enforce its provisions, address problems and make adjustments as indicators evolve, things could begin to fray. And public support is vital to the ACA’s survival.

One core component of the ACA that’s vulnerable is the essential health benefits — a provision that set a basic bar to ensure that if you’re mandated to buy something, it should provide you with something of value. Health and Human Services Secretary Tom Price has the power to impact the essential benefits through the regulatory process. And because he tried just that as a member of the House — his ACA replacement, the “Empowering Patients First Act,” eliminated essential benefit requirements — there’s reason to believe he’d be open to attempting the same thing as HHS secretary.

In addition, Trump signed an executive order in January directing federal agencies to ease the fiscal burden that the ACA might have on people and states (that’s code for pulling back enforcement). As a result, the IRS announced that it would continue processing tax returns that don’t disclose health insurance status, which could present an easy way for people to skirt the ACA’s individual mandate. If you think of the ACA as a bicycle tire, the individual mandate is the hub. Let it quietly crumble and the spokes go too.

That’s all to say that the ACA isn’t out of the woods just yet. So, let’s briefly look at just some of the consequences of dropping or weakening the ACA’s essential health benefits and easing coverage mandates.

• Hospital care and emergency care: According to a 2015 federal report, hospital uncompensated care costs were $7.4 billion lower in 2014 than they would have been if insurance coverage had remained at 2013 levels. That’s a whopping 21 percent reduction in uncompensated care spending. Five billion dollars of that reduction came from states that expanded Medicaid eligibility. This 2015 study found each additional uninsured person costs local hospitals $900 each year in uncompensated care. This one found that Medicaid expansion states experienced a decrease in uncompensated hospital costs of 3.1 to 4.1 percentage points of operating costs. (Adding this last one in there because so many states haven’t expanded Medicaid.)

• Pregnancy, maternity and newborn care: According to a 2011 federal report, less than a year after the ACA was signed into law, of the then-currently marketed plans submitted by health insurance companies to Healthcare.gov, 62 percent of enrollees did not have maternity coverage. Not having maternity coverage is expensive: This study found that from 2004 to 2010, the price insurers paid for childbirth rose between 41 and 49 percent depending on the type of birth. The average price for pregnancy and newborn care was $30,000 for vaginal delivery and $50,000 for a C-section. Before the ACA — the days when the free market reigned in much of the individual market — just 6 percent of health plans available to 30-year-old women in states where maternity care wasn’t required on the individual market actually offered the benefit.

• Mental health and substance abuse: That 2011 federal report of the then-currently marketed plans submitted to Healthcare.gov found that 34 percent of enrollees didn’t have substance abuse coverage and 18 percent lacked mental health coverage. This federal report found that behavioral health problems are the second-most common pre-existing health condition, affecting 45 million Americans. Thankfully, between 2010 and 2014, the number of Americans with a pre-existing condition who went uninsured for a full year dropped by 22 percent. The recent Republican plan didn’t target the ACA’s pre-existing condition protections. But a weakening of the essential health benefits could mean that even if people with behavioral health problems weren’t barred from the insurance market, the services they need might not be available.

• Pediatric services: As of June 2013, more than 28 million children enrolled in Medicaid and another 5.7 million in the Children’s Health Insurance Program depended on the programs for timely access to doctors when they’re sick. This 2016 study found that 2.8 million children gained coverage under the ACA, a more than 41 percent reduction in the children’s uninsured rate. In states like Alabama, Mississippi and South Carolina, the number of uninsured children fell by more than half. In 2014, the rate of U.S. children without health coverage fell to a historic low of 6 percent. Researchers estimate that if the ACA is repealed, nearly 4 million children would lose their coverage by 2019.

This is what Trump told ABC News in January: “Just so you understand people talk about Obamacare. And I told the Republicans this, the best thing we could do is nothing for two years, let it explode. And then we'll go in and we'll do a new plan and -- and the Democrats will vote for it. Believe me.”

Let’s take him seriously.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for 15 years. Me and my family depend on the ACA for access to quality health care.