What to Expect From the Next Congress on the ACA

This was published as a Wall Street Journal Think Tank column on November 7, 2014.

Since the outcome of Tuesday’s elections became clear, a lot has been said, and threatened, about repeal of the Affordable Care Act.

Republican control of the next Congress is likely to bring ACA challenges in two flavors. There will be early “statement legislation” to repeal the law and possibly to repeal the ACA’s individual mandate, a linchpin of the law that spreads risk and makes its insurance market changes work. These bills, intended to honor election promises to the Republican base, would be vetoed by President Barack Obama if they pass.

Then there is likely to be a series of legislative efforts to chip away at the ACA. One could be, as House Speaker John Boehner mentioned on Thursday, repealing the Independent Payment Advisory Board, a not-yet appointed commission with power to trigger reductions in Medicare payments if spending increases exceed certain levels and Congress does not come up with an alternative approach. Another might be repealing or altering the requirement that larger employers cover their workers or pay a penalty, likely by changing the definition of full-time workers from 30 hours per week to 40. Another could be introducing a new “copper”-level insurance plan that has higher deductibles and patient out-of-pocket costs. An effort to repeal a medical device tax that helps finance the law–something mentioned by Sen. Mitch McConnell on Wednesday–is also widely expected.

But none of these likely proposals strikes at the core of the ACA: its coverage expansions and insurance reforms. These would continue regardless of whether such changes were made or how fiercely the battle over them is waged.

Some who intend to advocate these changes see provisions such as the IPAB or the employer mandate as an overreach or too big an expansion of government. There are policy arguments for and against each of these likely changes. But for most people, opposition to the ACA isn’t about the details; Obamacare is mainly a proxy for their dislike of the president and their unease about the nation’s direction. The issues that would be the focus of these legislative proposals are mainly the concerns of insiders and such interest groups as business and medical device makers.

Another challenge will be keeping these legislative proposals in perspective. It’s easy to imagine “new challenge to Obamacare” headlines scrolling across the bottom of cable-news feeds as, perhaps, a bill to repeal the employer mandate is proposed in Congress. That would be an important story to cover, but small businesses are exempt from the ACA’s employer mandate and virtually all major employers already cover their workers, so the effect of repealing the employer mandate would not be large. As proposals to modify the ACA are introduced in the new Congress, it will be critical for the media to provide perspective, explain what proposals mean for people, and distinguish between small changes and ones that would cut to the core of the law.