By Ashley Fuoco Antonelli, Contributing Editor
During his first speech to a joint session of Congress last year, President Trump called on lawmakers "to repeal and replace Obamacare," firing the starting pistol in a year-long debate on wide-ranging health reform proposals that, ultimately, stalled.
Fast forward to this week: Trump again spoke before a joint session of Congress—but in his State of the Union address Tuesday, he briefly mentioned health reform, and he didn't say anything about repealing the ACA. And according to some experts, Trump's silence on the issue signals—at least at the federal level—that attempts to repeal the ACA are no longer a GOP priority, and that the ACA's future might instead be shaped by the states.
Where ACA repeal stands in Congress
Trump is not the only Republican who seems to have moved on from ACA repeal. In recent months, Republican congressional leaders have gone from pitching ACA repeal as a possibility for 2018 to barely mentioning it at all.
Many experts say Republicans' recent silence on ACA repeal reflects a major policy shift: that the party, which since 2010 had continuously vowed to repeal the ACA, no longer sees it as a viable priority—particularly in the Senate, where Republicans currently hold a narrow 51-49 majority. Sen. John Thune (R-S.D.) told Politico's Burgess Everett, "It would be a heavy lift. I think everybody knows." Thune added, "We sort of tested the limits of what we can do in the Senate last year. And we're one vote down from where we were then."
Even some conservative groups seem to have given up on ACA repeal. James Davis, EVP at Freedom Partners, told Axios' Caitlin Owens, "We would love to see Obamacare repealed ... but realistically, I don't think that's likely to happen this year."
Why the action could shift to the states
As ACA repeal becomes less of a focus at the federal level, some industry experts speculate that states might become the next battleground for health reform. In particular, states must decide how to handle their Medicaid expansions under the ACA—or, in some cases, whether to expand Medicaid at all.
So far, 32 states and the District of Columbia have expanded Medicaid under the ACA. But different states took very different approaches to their expansions, perhaps foreshadowing the varying paths that the remaining 18 states could take going forward.
To date, most Democratic-led states simply expanded their traditional Medicaid programs. However, the Republican-led states that have expanded Medicaid typically did so via waivers that allowed states to tailor the expansions by implementing certain requirements—such as cost-sharing and premium requirements—for certain beneficiaries. Former President Barack Obama's administration generally worked with Republican-led states to implement alternative Medicaid expansions, but the administration took a hard line against certain conservative proposals, such as work requirements.
However, the Trump administration last month opened the door to work requirements, and since then, according to the Washington Post's Jeff Stein, lawmakers in Idaho, Kansas, North Carolina, Utah, and Virginia have begun taking another look at Medicaid expansion. If those states expand their Medicaid programs, Stein notes "hundreds of thousands of Americans" could become "newly eligible for health coverage," though he acknowledges that the program's "reach into red states" would be broadened "with a decidedly conservative bent."
It's worth noting that states also could seek to create their own individual mandate penalties—to take the place of the ACA's individual mandate, which Congress recently eliminated as of 2019—or pursue ACA innovation waivers to reform their health insurance markets. For instance, some states already have gotten CMS' approval for waivers to create reinsurance programs, but it remains to be seen whether other states will follow suit.
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