How the GOP plans to attack the ACA after King v. Burwell

'It's a five to 10-year effort,' to chip away at the law, ACA opponent says

After the Supreme Court ruling upholding the Affordable Care Act's (ACA) subsidies designed to help U.S. residents purchase coverage through the federal exchange, Republicans are considering other strategies to change the law.

The subsidies were being challenged in the case King v. Burwell. A ruling striking down the subsidies could have eliminated about $28.8 billion in subsidies to 9.3 million individuals in 34 states in 2016, according to an Urban Institute analysis.

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Efforts in states, Congress

Opponents of the ACA are now focusing on how to chip away at parts of the law in Congress and state legislatures.

For example, Republicans are aiming to repeal the law's medical device tax and the so-called "Cadillac tax" on high-cost employer-sponsored insurance plans. GOP lawmakers are considering using the budget reconciliation process to attack parts of the ACA, although President Obama likely would veto any such effort.

A "larger goal" of ACA opponents is for states to use federal waivers to opt out of the law's individual and small-group insurance mandates, Stephanie Armour reports for the Wall Street Journal. States can begin applying for such waivers in 2017, which allow them to create their own plans to provide residents with affordable health coverage. The plans would be required to meet certain requirements, such as:

  • Covering as many individuals as the ACA would cover;
  • Ensuring some consumer protections; and
  • Not adding to the federal deficit.

"Look, you can chip away at it and create portholes where people can escape," says American Enterprise Institute resident fellow Thomas Miller. "It's a five to 10-year effort. That's where it will go next, on a long-term trajectory."

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Meanwhile, Rep. Paul Ryan (R-Wisconsin) says that "full repeal is absolutely still the goal" and that GOP lawmakers are "now focused on having a replacement plan ready to move quickly in 2017 under a Republican president."


In addition, the ACA still faces legal challenges that could weaken the law.

For example, a lawsuit filed by House Republicans that challenges Obama's use of executive action in implementing the law's employer mandate and cost-sharing reductions—which help some exchange plan enrollees pay for out-of-pocket costs—is still pending.

Other pending legal cases against the ACA include more than 50 suits challenging the law's contraceptive coverage rules (Armour, Wall Street Journal, 6/26; Firth, "Washington Watch," MedPage Today, 6/26; Scott/Johnson, National Journal, 6/25).

The takeaway: After the Supreme Court's ruling in King v. Burwell, opponents of the Affordable Care Act are aiming to chip away at the ACA piece-by-piece in an effort to weaken and eventually repeal the law.

Have King v. Burwell questions? We've got answers

Want to understand the impact of the Court's decision? Join the Advisory Board's popular "Pulse Check" panelists as they break down the Supreme Court's decision on the Affordable Care Act, the latest data on ACOs and bundled payments, and the industry's continued shift toward value-based care.


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