From John McDonough, Holes in the ACA: A Damage Assessment, an evaluation of the modifications to the Affordable Care Act (Obamacare) since it was enacted:
By my count … there have been eight consequential, substantive changes to the ACA since its signing in March 2010. Seven were done by Congress and one by the U.S. Supreme Court (SCOTUS). I list them in order of consequence, recognizing that many will disagree with my rankings:
1. Medicaid Expansions Are Voluntary for States (Title II)…
2. The CLASS ACT is repealed in toto (Title VIII)…
3. $5B cut from the Prevention and Public Health Fund (Title IV)…
4. Funding for Community Health Centers is cut (Title V)…
5. An I.R.S. information-reporting requirement on payments to corporations was repealed (Section 9006 of Title IX)…
6. Congress twice imposes new penalties on Insurance Exchange subsidy recipients whose incomes increase over the course of a coverage year (Title I)…
7. Unspent funding for Health Insurance Co-ops is rescinded (Title I)…
8. “Employee Free Choice” vouchers are eliminated (Title X)…
…
No contest, the biggest damage and biggest blow to the structure and integrity of the ACA came from the Supreme Court’s decision to make Medicaid expansion a state option. CLASS is prominent because it represents the repeal of an entire title of the ACA, even though the actual harm to individuals from repeal is debatable.
Of the others, I suggest that items 3 (Prevention Fund cuts), 4 (Health Center cuts), and 6 (penalties for subsidy recipients with income changes) are the most significant. All three can be fixed by a future Congress, so the damage is not as enduring at that from items 1 and 2.
Overall, given the scope and intensity of opposition to the Affordable Care Act for the past 34 months, it could have been a lot worse. The United States’ health reform law has been banged and bruised more than a little, and it is standing tall.
Based on the details he provided, repeal of the IRS reporting requirement doesn’t sound like a bad thing to me – a well-intentioned rule but likely to be a nightmare in practice. All the other items sound like legitimate hits to the ACA though.
My overall opinion of the ACA? Not great but an improvement over the status quo. The main positive is that people who were previously denied coverage can now obtain it. That’s a big positive. The main negative is that there’s no cost control on the insurance options. We’re mandated to buy insurance. The risk is that the only options available to us require that we significantly overpay (relative to the rest of the developed world) for what we get – top dollar for mediocre coverage, short money for lousy coverage, etc. That’s a big negative. That said, I choose to see the glass as half full and take my chances that we can fix the problems with the ACA in the future.