The decision on March 24, 2017 to indefinitely postpone a vote on the American Health Care Act (AHCA) was a thrilling, but temporary, victory in the campaign to protect the Affordable Care Act (ACA) and Medicaid. Opponents of the ACA still have many opportunities to undermine the ACA and Medicaid. While news reports of new pushes to pass the an amended AHCA or other ACA repeal legislation are likely to persist, many of the most credible threats to the ACA and Medicaid will come from more indirect sources – decisions made by the Trump administration, decisions made by private insurance companies, from budget cuts, or even from offhand comments or tweets. These subtler dangers to our health care system pose serious threats in their own right, but also represent grave risks in the battle for public opinion. We must be ready to drive the public narrative before any sabotage take place, so that any blame for an underperforming ACA system is placed squarely at the feet of those who have deliberately undermined it.

ACA/Medicaid threats on the horizon

Here are threats to the ACA and Medicaid that remain even if there is not an imminent vote on an ACA repeal bill:

• Discontinuing Cost-Sharing Reduction payments: The ACA provides subsidies – called Cost-Sharing Reductions (CSRs) — to help people with lower incomes pay for out-of-pocket costs (e.g., deductibles and co-payments). Six million people get CSRs and in 2016, 156,500 Illinois Marketplace enrollees received CSRs. The Trump administration has the power – right now – to end these subsidies thanks to a 2015 lawsuit alleging these payments are illegal. This the most clear and immediate risk to the ACA. Without the CSRs, actual premiums paid by clients could go up by 20% or more, insurers would drop out, and enrollment would decrease. This is already causing uncertainty and real harm to the prospects for the 2018 plan year, but could be easily addressed if the Trump administration publicly stated their intent to continue these payments, or if Congress appropriated the necessary funds.

• Poor private insurer participation in the Marketplace: The ACA Marketplace depends on participation by private health insurers. Exits by large insurers such as United Healthcare and Aetna over the last year or two have damaged the law’s standing in the eyes of many and resulted in reduced competition and choice for enrollees. This is a problem – and it could get much worse. Insurers will be announcing from now until June their plans regarding 2018 participation and what they will charge in premiums. High profile exits or large premiums increases could destabilize the market and breathe new energy into the push to repeal the ACA. The uncertainty surrounding the future of the ACA contributes to the flight risk; conversely, agreements to resist short-term tinkering could stabilize the market.

• Administrative policy changes: Many provisions of the law are determined by the Secretary of Health and Human Services and other members of the administration. A number of changes – that the administration can make more or less unilaterally – could weaken the ACA. Some potential changes have already occurred through the “Market Stabilization Rules” that were just finalized this month and some proposed changes include weakening enforcement of the individual mandate, removing funding from the navigator program, and changing the definitions for Essential Health Benefits. Some of these changes do not even require formal public notice and could fly under the radar while doing real damage. Medicaid is also at risk due to an intention to allow states to impose work requirements, premiums, and other barriers in the name of demonstration projects or waivers. We must continue to monitor these actions and publicize them.

• Policy riders: In Congress, controversial legislative changes are hard to pass on their own. They are instead often added to large pieces of legislation that need to pass, like government funding bills. These amendments to larger pieces of legislation are called ‘riders’ and they can do serious damage. In fact, the premium increases seen in 2016 were due in part to a policy rider that prohibited funds from being used to stabilize premium prices (known as risk corridor payments). This is technical and sneaky; but it can have a real impact. Legislation to fund the federal government before a government shutdown is being debated this week. We must be prepared to advocate against attempts to deconstruct the ACA through this back-door.

• Children’s Health Insurance Program reauthorization: The biggest “must pass” health care legislation on deck in 2017 is the reauthorization of funding for the Children’s Health Insurance Program. Opponents of Medicaid could use this reauthorization as a bargaining chip to undermine the adult Medicaid program or other federal health programs. Legislation is likely to be negotiated over the summer and will need to be passed by Sept. 30. We need to monitor progress of this legislation.  It is not too soon to begin talking to representatives and senators about this important re-authorization.

Stay involved and speak out

This laundry list of horrors does not have to come to pass. Advocates must stay vigilant as we navigate this new, less straightforward phase of the campaign. We can and must speak out about them to make sure policy makers know we’re watching. Sign up for Protect Our Care – Illinois email alerts and follow us on Twitter and Facebook to stay up to date.

The most pressing issue for now is funding for the Cost-Sharing Reductions. Please view our CSR fact sheet for ideas on how to speak out.

The opponents of the ACA are counting on us letting our guard down and being able to slip these changes in unnoticed. But we can make them think twice if we let them know we have our eyes on them. And with commitment and a little luck, we can protect the ACA and Medicaid – now and for future generations.