ACA repeal more difficult as U.S. gets used to popular provisions

Last week, on the sixth anniversary of the signing of the Affordable Care Act into law, White House officials touted all of its successes. The uninsured rate in America is at an all-time low of 9%, said HHS Secretary Sylvia Mathews Burwell, and insurers can no longer reject people with pre-existing conditions.

But on the same day she listed the healthcare reform law's accomplishments, the U.S. Supreme Court was hearing a case that contests the ACA's contraception coverage mandate. In fact, the high court has heard a number of challenges to the law with more likely to come.

The Republican vow to “repeal and replace” is still a staple of most stump speeches even as the ACA garners limited attention on the presidential campaign trail.

Some aspects of the law, however, have been popular with the public and among politicians on both sides of the aisle.

Provisions such as allowing children to remain on their parents' insurance until age 26, and requiring insurers to cover people with pre-existing conditions are almost certainly here to stay.

Keeping just those measures, however, would be difficult without the requirement that everyone have health insurance, analysts say.

Most of the coverage increase has come from the expansion of Medicaid in more than 30 states, while employer-based coverage has remained steady over the past six years.

More than 6.1 million young adults have received insurance under the ACA, including 2.3 million who signed up between 2010 and 2013 under the provision allowing them to stay on a parent's health plan until age 26, according to HHS.

About 76 million Americans have received expanded preventive-health services with no out-of-pocket costs because of the ACA, according to the agency. Polls show many Americans, however, are still not aware they can receive those services without cost sharing.

Before the ACA's guaranteed-issue rule, which banned insurers from discriminating against those with pre-existing conditions, many people struggled to obtain or afford insurance because of their medical history.

A Kaiser Health Tracking Poll from June 2013, months before the guaranteed-issue provision went into effect, found that 49% of adults said they or someone in their household had a pre-existing condition. One-quarter of those respondents reported being denied insurance or given a premium increase, and 9% said they had stayed at a job just for the health insurance.

An HHS analysis in 2012 similarly found that as many as half of the nation's adults had some type of pre-existing condition.

These ACA provisions, individually, are popular among Americans. Another Kaiser poll found 70% to 80% approval for the changes to preventive care, dependent extension, subsidies and guaranteed issue.

Katherine Hempstead, director of health insurance coverage for the Robert Wood Johnson Foundation, said the three key provisions of the ACA are the individual mandate, tax credits to help Americans buy insurance, and the ban on turning away those with pre-existing conditions.

The individual mandate may be controversial, but the other two provisions would be difficult to roll back. And all three are needed for the system to work, she said.

“Sometimes people talk about that as the three legs of the stool,” she said.

Getting rid of tax credits would be devastating for the individual market. People who receive them are grateful to take them, but those who don't get tax credits also rely on the large risk pool for the market to function. And the markets are all connected, so those with employer-sponsored insurance would feel the effects as well, Hempstead said.

Coverage for pre-existing conditions has been a huge achievement and a cultural change that shows a shift in values. It would be surprising for any state to return to medical underwriting, she said.

All the Republican presidential candidates have said they would repeal and replace the ACA, but they have given few details about how they would replace it.

Donald Trump, who leads in delegates, released a seven-point plan relying heavily on allowing consumers to buy insurance across state lines and issuing health savings accounts. He has said in debates that he would make sure people with pre-existing conditions would be able to get coverage, but his plan does not mention it.

An analysis by the Committee for a Responsible Federal Budget found that Trump's plan would cause nearly 21 million people to lose coverage.

Texas Sen. Ted Cruz has laid out three main points in his plans for replacing the ACA. Like Trump, he wants to expand HSAs and allow interstate insurance purchases.

He has also called for de-linking health insurance from the workplace. He does not mention pre-existing conditions.

Among the Democratic candidates, Hillary Clinton has said she wants to build on the success of the ACA to achieve universal coverage. Her rival, Vermont Sen. Bernie Sanders, campaigns on a Medicare-for-all plan.

Talk of repealing the health reform law may win applause for Republicans on the campaign trail, but “it's a lot easier to talk about it than it is to do it,” Hempstead said.

Sara Collins, vice president of healthcare coverage and access at the Commonwealth Fund, said millions of people have benefited from the subsidies and essential health-benefit requirements for health insurance, along with young people who can stay on their parents' insurance longer, and Americans who have pre-existing conditions.

These provisions, working together, have made the ACA successful in significantly lowering the number of uninsured, she said.

“I think taking that away would remove a consumer protection that millions of people are benefiting from,” Collins said.

Some conservatives have suggested a continuous coverage provision instead of an outright ban on pre-existing condition limitations. But many people have gaps in their coverage that would make them vulnerable to being cut out, she said.