DOJ Will No Longer Defend Affordable Care Act by Nicky Riordan
In lieu of a legislative victory to repeal or replace the Affordable Care Act (ACA) last year, the Trump Administration and allies in Republican-led states are finding their second wind in the effort to dismantle and undermine the law on multiple fronts. Most notably, recent developments in a key legal case against the ACA and dueling state-based efforts regarding Medicaid expansion are driving the conversation.
With various provisions of the ACA already standing on precarious ground, the state-led fight to dismantle it gained momentum recently from an unlikely source - the Department of Justice. Breaking with precedent, the DOJ signaled that it will no longer use resources to defend the ACA from legal challenges, a formal decision that constitutes just one piece of a larger effort to undermine the ACA at a pivotal time for both insurers and advocates.
The current legal battle is being waged in a Texas federal court between 20 Republican-led states and 17 Democratic-led states over the constitutionality of the ACA as a whole in light of Congress’ revocation of the tax imposed by the individual mandate through the recent budget bill. Those bringing the case are also asking that provisions of the law be suspended until the case is decided, which would throw insurance markets into chaos and upend the system, essentially achieving their aim without legal action.
Regardless of the outcome of this case, the DOJ decision will affect decisions insurers are currently making about rate-setting and coverage for next year, and uncertainty from the Executive Branch will likely result in large premium increases and volatile insurance markets. These efforts create a self-fulfilling prophecy for the ACA, which has managed to hold up through various attacks but is more vulnerable than ever.
On a different front, Medicaid expansion is back in the spotlight as well, as some states work to expand it and others attempt to limit its impact. Some unlikely Republican-led states are witnessing a public effort to expand Medicaid, as voters in Utah, Idaho, Montana, and Nebraska are working to place measures for expansion on statewide ballots this November.
To date, 34 states and the District of Columbia have expanded Medicaid voluntarily and now 3 states are actively considering expansion. This is not surprising, as research shows that Medicaid expansion states experienced significant coverage gains, increased utilization and affordability of care, and a reduction in uncompensated care costs for hospitals and clinics.
ACA opponents, on the other hand, are trying to pass work requirements at the request of the Trump Administration to weaken effects of the existing expansion. Last month, New Hampshire became the fourth state to institute a work requirement, after Indiana, Arkansas, and Kentucky, and an additional six states have requests in to do the same.
As I have written previously, the addition of work requirements to the Medicaid program are ineffective at saving the government money or improving care, as more than half of able-bodied Medicaid enrollees are already working at least part time, and eligible people who need this program the most will likely lose coverage due to confusion over new reporting requirements or failure to comply in time with state requests for information.
The renewed power of federalism surrounding ACA implementation is an interesting turn in the debate, but the fact remains that the most important thing hanging in the balance now is public opinion. Congressional Republicans could not repeal the law because it held up to public scrutiny and personal experience, but as prices rise and coverage weakens, it will be easy for opponents to make the case against it, which may be exactly what these efforts aim to achieve.
Nicky Riordan (@nriordan120), Political Analyst, Utica College Center of Public Affairs and Election Research