The ACA Post-Tax Bill: Is the Glass Half Full or Half Empty?

By Jill Zorn |


The terrible tax bill that just passed has huge negative implications for health care and the health of the Affordable Care Act (ACA).  But the ACA, while weakened, is still standing.

Individual Mandate

The tax bill eliminates the individual mandate, allowing healthier people to drop coverage with no penalty.  Experts anticipate this will leave an insurance pool that has a greater proportion of people with health challenges who use more health care services, leading to an estimated 10% increase in premiums.

The ACA relies on a carrot and stick approach to incentivize people to purchase health care in the marketplaces.  The mandate is the stick, charging people a fee if they don’t sign up.  But the repeal of the mandate hasn’t touched a very powerful carrot – subsidies to help people pay for coverage.

Most people who sign up for insurance are protected from the full cost of premiums.  In Connecticut about 75% of the approximately 100,000 people enrolled in coverage through Access Health CT qualify for subsidies.

And, although the timeline has now slipped to January, it is still possible that a vote on two bills that are designed to improve the ACA marketplaces, could still happen.  This vote was “promised” by Senate Republican leaders to Senator Susan Collins in return for her vote to support the tax bill.

So, despite Republican boasting that the ACA is now “unworkable”, losing the mandate does not mean the end of the ACA.  Instead, the most unpopular part of the ACA has been repealed, while the other much more popular features, like protecting people with pre-existing conditions and the subsidies remain in place.

Budget Cuts

Perhaps an even bigger threat to health care posed by the tax bill is the huge deficit it is creating. The battle over the 2019 budget promises to be a huge fight.  Already, Republicans, who created a $1.4 trillion deficit with the tax bill, are planning significant spending cuts, including Medicaid, Medicare and ACA subsidy funding.

But does Congress have the votes to make these cuts?  Don’t forget all direct efforts to defund the ACA and block-grant Medicaid failed this year.  With the election of Doug Jones in Alabama, the Republican majority in the Senate is down to two votes.  Recent polling by the Kaiser Family Foundation shows that even Republicans, by high numbers, oppose cutting Medicare and Medicaid to pay for tax cuts.

Even as this blog is being written, there is some speculation that Trump may not even sign the tax bill until 2019, to avoid an automatic $25 billion cut to Medicare.

Keep Playing Defense and Offense

So, is the glass half full or half empty?  Read The Stealth Repeal of Obamacare, if you want to get more depressed.  Or read Obamacare Will Survive if you want to feel more hopeful.

But the best thing you can do is take action, and there will be lots of opportunities to do that in 2018.

On the federal side, the focus will have to be on defending against drastic cuts to health care programs.  We will want to demonstrate support for Connecticut’s Congressional delegation as they do everything they can to protect against attacks on these crucial programs.

Demanding action at the state level during the upcoming Connecticut General Assembly Session will be our chance to play offense.

There are many positive actions that states can take to improve the functioning of the ACA.  Already, discussions are underway about how best to do that in Connecticut.

Connecticut can impose its own version of the individual mandate, or consider other ways to boost enrollment.  And there are many other possible options under consideration for stabilizing the ACA marketplace and counteracting Trump Administration sabotage.

And it’s time for Connecticut to consider bolder steps, beyond ACA fixes, to move us closer to universal health care.

Watch this space for more information about advocacy opportunities to play defense and offense in 2018.

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