Burwell: More Work To Do To Implement ACA, Expand Coverage

Although the Supreme Court last week ruled to uphold the Affordable Care Act's subsidies to help U.S. residents purchase coverage through the federal exchange, HHS Secretary Sylvia Mathews Burwell on Friday said there is still work to be done in regard to the law, Reuters reports (Cornwell, Reuters, 6/26).

Background

The subsidies were challenged in the case King v. Burwell, but the Supreme Court on Thursday voted 6-3 to uphold them. 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. Observers say the ruling leaves the law on more stable ground for the remainder of President Obama's time in office (California Healthline, 6/26).

Burwell Discusses State Exchanges, Future Work on ACA

Burwell said she does not think states currently running their own exchanges will drop them in favor of relying on HealthCare.gov in light of the ruling (Reuters, 6/26).

Stakeholders on Friday said the court's ruling could end states' efforts to establish their own exchanges under the ACA and might lead to some already-established state exchanges switching to the federal exchange (California Healthline, 6/26).

However, Burwell said HHS would "work with states that want to do state-based exchanges" and run federal exchanges in states that do not set up their own (Reuters, 6/26).

Meanwhile, Burwell said officials must now "build on the progress" the ACA already has made, such as getting more states to expand their Medicaid programs under the law. Burwell said HHS "welcome[s] the opportunity to talk about how a particular state needs to do this," adding, "We think there's a lot of space to get to agreement" on alternative Medicaid expansions in states that do not want to expand their traditional Medicaid programs. She noted, "I'm an optimist about the Medicaid issue in terms of being able to make some progress" (Sun, Washington Post, 6/27).

Further, Burwell said enrollment in health plans under the law needs to continue to rise. Burwell also noted the need for education efforts to ensure individuals newly enrolled in coverage understand how to use their benefits.

Overall, Burwell said officials "have work to do," adding that the ACA "can be better." She said she intends to spend the rest of her tenure at HHS working to implement the law (Agnes Carey, Kaiser Health News, 6/26).

ACA Still Faces Challenges

Meanwhile, the ACA still faces legal challenges, the New York Times reports.

For example, a lawsuit filed by House Republicans that challenges Obama's use of executive action in implementing the law is still pending (Pear, New York Times, 6/26).

Other pending legal cases against the ACA include more than 50 suits challenging the law's contraceptive coverage rules.

Administration officials have said they believe the courts will side with the federal government in such cases (New York Times, 6/26). University of Michigan School of Law professor Nicholas Bagley also said it seems "[t]he overall message is that the courts are not going to stand in the way of the [ACA], that they're going to leave it to the political process" (Firth, "Washington Watch," MedPage Today, 6/26).

Further, the law faces lingering opposition and structural issues, like rising health plan premiums and limited provider networks in exchange plans, according to Politico. In addition, some states continue to struggle with technological and financial challenges related to running their own exchanges under the law. In addition, Republican governors continue to oppose the law, which could mean states will shy away from expanding Medicaid.

Republicans in Congress also could still try to repeal the law, either in its entirety or piece by piece (Haberkorn/Pradhan, Politico, 6/26). According to The Hill, Republican lawmakers are working toward a plan to use budget reconciliation to repeal the ACA, which Senate Majority Leader Mitch McConnell (R-Ky.) views as the only means the GOP can use to get an ACA repeal measure to Obama for consideration. According to The Hill, Obama would veto such a measure (Bolton/Sullivan, The Hill, 6/26).

Michael Sparer, chair of the Department of Health Policy and Management at Columbia University's Mailman School of Public Health, said he doubts the ACA will be repealed, even if Republicans hold their majority in Congress and a Republican president is elected to office in 2016. He noted, "Right now the ACA is firmly cemented and firmly implanted as the law of the land."

Still, the upcoming presidential election likely will feature fierce debate over the ACA, according to Stephen Parente, Minnesota insurance industry chair of health finance at the University of Minnesota. Parente said the Supreme Court's ruling in King v. Burwell likely will "heat up the debate," with "Republicans ... expected to propose a viable alternative to" the ACA, while "Democrats won't be given a free pass." According to Parente, GOP presidential candidates could push for one of the ACA replacement plans introduced by Republicans in Congress. Kaiser Family Foundation Senior Vice President for Special Initiatives Larry Levitt added, "There's still a lot that the next president could do to shift the law left or right" ("Washington Watch," MedPage Today, 6/26).

ACA Opponents Consider Smaller Attacks

In related news, opponents to the ACA are now considering smaller attacks on the law, the Wall Street Journal reports.

Thomas Miller, a strategist who helped to build the plaintiffs' case in King v. Burwell, said he will be holding meetings for ACA opponents on how they can mount smaller attacks against the ACA. However, he noted future legal challenges against the law could be more difficult to wage following the Supreme Court's ruling in King.

Instead, opponents to the ACA said efforts to dismantle the law should take place in Congress and state legislatures, where legislation can be passed that would knock down smaller provisions of the law. One such effort is repealing the law's medical device tax, which the House voted to do earlier this month.

In addition, states could seek federal waivers that would allow them to opt out of the law's individual and small-group insurance requirements. According to the Wall Street Journal, states can begin applying for such waivers in 2017. The waivers would allow states the flexibility 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 (Armour, Wall Street Journal, 6/26).

Some Govs Push for Medicaid Expansions

Meanwhile, some governors who support the ACA are renewing efforts to encourage their states to expand their Medicaid programs under the law, National Journal reports.

The governors are citing the King ruling as a reason to embrace all of the ACA's provisions. Virginia Gov. Terry McAuliffe (D) in a statement called the decision "a clear sign that now is the time to drop cynical efforts to prevent families from accessing care that will make their lives better." He added, "With this issue decided, I hope we can now put partisan politics aside and help 400,000 Virginians get access to health care by bringing our taxpayer dollars home to close the coverage gap."

Alaska Gov. Bill Walker (I) in a statement said, "Now it's important that we continue to work toward Medicaid expansion, so more Alaskans can receive the health coverage they need." In addition, Missouri Gov. Jay Nixon (D) also called for Medicaid expansion in his state.

However, the governors could continue to face opposition from their state legislatures, which have refused to approve Medicaid expansion (Owens, National Journal, 6/26).