At the beginning of 2012, the Affordable Care Act (ACA) was disliked by almost half of the public, faced formidable challenges in the courts, and seemed to be damaging Barack Obama’s prospects for reelection. By the end of the year, this historic law had made a stunning comeback, and it is well positioned for a full phase-in in 2014.
Two things happened. In a narrow 5-4 ruling in June, the Supreme Court upheld most provisions of the health reform law, including the mandate that virtually all Americans have insurance. And in the presidential elections in November, Barack Obama defeated Republican Mitt Romney, who had vowed to strike the law down on “day one” of his presidency.
Public opinion warmed up a bit. In a poll by the Kaiser Family Foundation just after the election, 43% gave the ACA a favorable rating, compared with 37% a year earlier. It will be interesting to see opinion polls in 2014, the start of the insurance mandate, which the public has never liked but may not be so bad once it happens. Also, insurers will be forced to cover preexisting conditions and state insurance exchanges will open, both of which have been widely popular.
The ACA helps minorities and minority nurses in several ways. In addition to expanding coverage for millions of uninsured minorities, it provides higher loan levels for nursing students, funds cultural diversity in nursing, and provides grants to develop specific nursing specialties. It also promotes advanced practice nursing and primary care.
But the backlash against health reform is far from over. Even though a Democratically-controlled Senate stands behind the president and his reform law, the ACA faces determined opposition from a Republican-run House of Representatives. In its last session, the House voted no less than 33 times to repeal, defund, or remove provisions from “Obamacare,” only to see them defeated in the Senate.
Deadlines forcing bipartisan agreements on the federal budget, such as the fiscal cliff and the debt ceiling, give House Republicans plenty of opportunities to push for cuts in the health care law. President Obama has already allowed one cut. To temporarily extend unemployment benefits, he signed a bill last February that removed $6.3 billion over 10 years from the ACA’s Prevention and Public Health Fund. GOP activists have targeted the fund, calling it a “slush fund” because it is not tied to specific initiatives. In 2010, the fund spent $31 million for advanced nurse education and $14.8 million for nurse-managed care centers.
Will Republicans succeed in forcing through more cuts this year? The White House said the ACA was off the table in the fiscal cliff negotiations, and the president’s election victory puts him in a stronger position to back that up. But the fiscal cliff is just the opening salvo of a year that promises endless partisan brawling over fixing the tax code and restructuring entitlements like Medicare.
Another reason Republicans could push hard in 2013 to defund the ACA is that time is running out. After the ACA launches its key reforms at the beginning of 2014, the bulk of the new law will have been implemented. It would be hard to put the genie back in the bottle.
The law’s expansion of coverage in 2014 will have a huge impact on minorities, who suffer from the lowest levels of coverage right now. According to the United States Census Bureau, 19.5% of African Americans and 30.1% of Hispanics do not have health insurance, compared with 11.1% of non-Hispanic whites.
Uninsured minorities applying for Medicaid or buying policies in new health insurance exchanges will have to educate themselves. Last summer, Aisha Hakim, a former president of the Westchester County chapter of the National Black Nurses Association in New York State, said that people of color have yet to fully understand their options, and the federal government “could do a little more in terms of educating the public.”
The law also bars an estimated 12 million undocumented immigrants from getting subsidized coverage or Medicaid coverage. Some fear lack of coverage could make these people easily identifiable to US immigration officials.
Meanwhile, some states will refuse to expand Medicaid eligibility, as the law directs. The ACA provides generous federal funding for states to open Medicaid to people with incomes as high as 133% of the poverty level, but the Supreme Court decision allowed states to opt out. As of late November, eight states––including Texas and Georgia––had done so, five more were leaning that way, and 20 had not yet decided.
As the new law is fully implemented, it will face a number of other challenges. Will the insurance exchanges be effective? To function properly, they need the right mix of healthy and sick people. Will subsidies for the exchanges be seen as too expensive? Subsidies are expected to cost the federal government $574 billion between 2012 and 2019. Will employers drop coverage rather than submit to the mandate? Employers have to pay penalties if they don’t cover their workers. And finally, will the ACA actually control health care costs? The law has launched a number of new initiatives designed to lower costs, such as accountable care organizations and patient-centered medical homes.
The midterm elections in November 2014 will be a crucial test of the fully implemented law. If the 2014 implementation is messy, Republicans could expand their seats in Congress and maybe even defund parts of the law, such as some subsidies for the exchanges. But whatever happens, this groundbreaking measure is here to stay. “Once people get the benefits,” said Democratic strategist Bob Shrum, “you can never take them away.” MN