Election Will Have Long-Term Consequences for ACA.

Regardless of the outcome, the federal election in November is likely to have “fundamental consequences” for the future of the Affordable Care Act (ACA) and related health reform proposals, says a School of Public Health researcher writing in JAMA Internal Medicine.

In a Viewpoint article, co-authors David Jones, assistant professor of health law, policy & management at SPH, and John McDonough, professor of public health practice at the Harvard T.H. Chan School of Public Health, say that the ACA “has yet to become settled policy” and will likely undergo change, no matter who is in the White House. What kind of change largely depends on whether Republicans retain control of the Senate, they say.

If Hillary Clinton wins and the Democrats secure a Senate majority, Democrats will still “struggle to enact ACA enhancements” if there is a Republican majority in the House, Jones and McDonough write. Clinton, the Urban Institute, and two other groups aligned with Democrats have proposed health reform agendas for 2017 that strengthen core provisions of the ACA. All four proposals assume that a Democratic president would block Republican attempts to repeal the ACA, and none call for establishing a single-payer system to finance health care, the authors say.

Clinton wants all 50 states to expand Medicaid and would encourage states to establish “public option” exchange plans, reminiscent of what many Democrats unsuccessfully sought when the original ACA legislation was considered by Congress. She also wants to make insurance coverage more affordable by increasing the value of premium tax credits for households with incomes less than 400 percent of the federal poverty level who buy insurance through an exchange. Clinton’s proposal would provide a tax credit for families whose expenditures exceed 8.5 percent of their household income, among other efforts to reduce consumer costs.

“A Democratic victory that included the White House and a Senate majority would likely further embed the ACA into state and federal health policy, and perhaps lead to further expansion and reforms,” Jones and McDonough write.

If Donald Trump wins and Republicans retain control of both chambers, a repeal attempt is likely, under plans advanced separately by Trump and House Speaker Paul Ryan. Their proposals would replace the ACA with legislation that permits the interstate sale of insurance, allows individuals to deduct the cost of health insurance premiums on their federal tax returns, and expands the use of health savings accounts.

“If Trump wins, Republicans are likely to do better in battleground states hosting competitive Senate races, enabling Republicans to maintain Senate and House control,” the authors write. “Less certain is whether the Republicans could maintain unity to dismantle key coverage portions of the ACA that would eliminate health insurance coverage for many of the 21 million low and lower-middle income people who have gained coverage in the last six years.”

While the authors acknowledge that attitudes about the ACA likely will not be key in deciding the election, the results will have “fundamental consequences for the future of national health reform,” they conclude.

—Lisa Chedekel