|By Kathy Greenlee, JD|
learned the Irish superstition that you should exit by the same door through
which you entered. The Affordable Care Act will most likely not have that option.
The door it entered is closed.
I also recently
revisited the unusual circumstances that allowed the ACA to become law. In early
2010, the Democrats held a 60-vote majority in the United States Senate. Then,
in August, Massachusetts Senator Ted Kennedy died. In the election for his
successor, Massachusetts elected Scott Brown, a Republican. Between the
November election and Scott Brown’s swearing in, the Senate approved the ACA.
When Senator Brown took office, the Democrats lost their super majority. The
House had already passed the law, so they quickly moved to pass the Senate
votes in the United States Senate is a big deal. The Senate rules are such that
the chamber requires a supermajority – 60 votes – to cut off debate and take a
bill to the floor for vote.
Law, Regulations and Money
The ACA is
anchored by three things: the law, regulations and money. Currently, the
Republicans have a majority but not a supermajority. They don’t have 60 votes
to pull the law off the books. They do, however, have enough votes to control
the money. The ACA will be made ineffective and inoperable because the funds
needed to make the law work will be removed. Money supports the subsidies for
qualified people who purchase insurance through the exchanges. Federal money is
used to match state money for Medicaid expansion and long term care rebalancing
incentives (incentives for states to purchase community rather than
institutional services for long term care). It takes money to close the
Medicare prescription drug plan donut hole.
and most active battles in Congress will focus on money. And that battle has
begun. The current 2017 federal fiscal year began on October 1, 2016. But,
Congress has not passed a budget for this current year. Congress intends to use
the current budget to gut the provisions of the ACA that are budget related.
Then, immediately thereafter, the Trump administration will present Congress
with a proposed 2018 budget and Congress will begin to work that budget this
summer. The ACA will likely remain on the books, but won’t be operable as a
comprehensive law. The non-budgetary sections will remain but will be largely
Congress assures the money dries up, the Trump Administration can begin the
process of rolling back the thousands of pages of regulations that support the
implementation of the law. Repealing regulations is time and labor intensive.
ACA regulation repeal will be a steady slog likely to drag on through most of
2017 and into 2018. Regulations are behemoths.
As you watch
events unfold, keep in mind the three anchors I mentioned earlier: the money,
the regulations and the law. The Republicans in Congress and in the White House
will drive the budget and the regulations. They won’t need Democratic support
to do so. But, to pull the remnants of the law and to pass a new law, Senate
Republicans will need to find Democratic allies to help them get the 60 votes
they need to cut off debate and pass legislation. The Democrats had 60 votes
when the ACA passed; the Republicans currently do not. The 60-vote door will
have to be unlocked in order to make new law.
Let’s talk in more detail about an ACA budget hot topic: Medicaid.
Kathy Greenlee joined the Center’s
staff as Vice President for Health Policy and Aging in November 2016 after
serving the past seven years as Assistant Secretary for Aging in the U.S.
Department of Health and Human Services.
Labels: Affordable Care Act, Medicaid