Expert panel says ACA here to stay despite outcome of looming presidential election

The upcoming presidential election will have far-reaching consequences on the future of healthcare in the U.S., but no matter the results, the changes already forged by the Affordable Care Act are here to stay, a panel of policy and legal experts said this week.

“I don't think you can unwind the ACA,” David Axelrod, former senior adviser to President Barack Obama and chief strategist during his political campaigns, said Monday. “Once 20 million people are covered, once the ban on pre-existing conditions is gone, once people who are under the age of 26 can stay on their families' health care plan until they're 26, it's very hard to unwind that,” he said.

These elements of the healthcare law have become central tenets to what people think a healthcare system should be. Moreover, polls show the majority of Americans don't want to repeal the healthcare law, he said.

He made his comments during a University of Chicago symposium Monday on the ACA.

Even so, the healthcare law is imperfect, and the rolling out of the HealthCare.gov exchanges has been anything but smooth. HHS announced late last month that unsubsidized federal exchange premiums would rise on average 25% next year, sparking renewed frustration among exchange shoppers. Republican presidential nominee Donald Trump jumped at the opportunity to rally support for repealing the law—a cause that's been a cornerstone of his campaign.

“The impression you get from people who are opposed to the ACA, including Mr. Trump, is everyone's healthcare is being affected,” Axelrod said. “Anybody who had an increase in their health insurance premium now thinks it was because of the ACA.”

In reality, few Americans will be affected by the jump in premiums because relatively few Americans are in the exchanges, he said. Moreover, most exchange shoppers will be insulated from the double-digit hikes because they are eligible for federal financial assistance.

The Obama administration knew the ACA as it was passed contained imperfections. For instance, the original legislation included a provision for risk corridors and assistance for insurance companies if the market turned out to be unbalanced, as it did, but Congress blocked the provision, which is now budget-neutral and can only pay out what insurers pay in. The administration also wanted to include a provision for marketing the exchanges to young, healthy people so as to balance out the risk pool which is largely characterized by older, sicker individuals, but it wasn't included in the final legislation, Axelrod said.

“There are a series of things like that all of which we knew would have to be fixed down the line,” he said. The results of the presidential election just a week away will have a lot say about whether these some of these fixes will ever occur.

But the ACA will majorly remain intact no matter how the American public votes Nov. 8.

“The main legal challenges to the heart of the ACA have been dispensed and ruled on by the Supreme Court in ways that have upheld the constitutionality of the main provisions of the ACA,” said Jennifer Nou, an assistant professor of law at the University of Chicago Law School.

While no one can really say what a Trump presidency would mean for healthcare, a Hillary Clinton presidency would likely lead to an expansion of accountable care organizations and bundled payments, said Dr. Thomas Lee, chief medical officer with Press Ganey Associates and a professor of health policy and management at the Harvard School of Public Health.

“There's an optimistic scenario for a Clinton election, which is that people figure out that we actually have to make this system work and the Republicans get something that they really want— an expansion of Medicare Advantage, which is too big to go away now,” he said. “In return, they actually support as oppose to sabotage the exchanges and other parts of health care reform.”

The federal exchanges, which are volatile now as consumers figure out what they want and insurers who initially underpriced adjust their exchange plan pricing, will eventually settle out in the next year or two. Regional insurers will be the ones to make the exchanges work, as national insurers jump ship, said Lee, who is also chairman of the Geisinger Health Plan's board of directors.

Geisinger is “expecting to more than double our exchange population” as Aetna pulls out of Pennsylvania markets, Lee said.

If the private insurers can't figure out a way to make the exchanges profitable, “people will want a government solution, because they don't want 20 million people to suddenly have no insurance.”