In its first five years, the Affordable Care Act has survived technical meltdowns, a presidential election, two Supreme Court challenges — including one resolved Thursday — and dozens of repeal efforts in Congress. But its long-term future still isn鈥檛 ensured. Here are five of the biggest hurdles remaining:
Medicaid Expansion. About 4 million more Americans would gain coverage if all states expand the state-federal Medicaid programs to cover people with incomes at or slightly above the poverty line. Republican governors or GOP-controlled legislatures, including Texas and Florida, have balked, citing ideological objections, their own budget pressures, as well as skepticism about Washington鈥檚 long-term commitment to pay for most of the costs.
Anemic Enrollment. Eighteen million Americans who are eligible to buy insurance in federal and state marketplaces haven鈥檛 purchased it. Those marketplaces have had particular trouble enrolling Hispanics, young adults and people who object to being told to buy insurance.聽 Federal funding used by state marketplaces to enroll people and advertise is drying up. Many state marketplaces haven鈥檛 figured out how to be self-sustaining. Vermont, Hawaii, Colorado and Rhode Island are among those states . The penalty for going without coverage next year to $695 per adult or 2.5 percent of family income鈥攚hichever is larger.
Market Stability. Nationally, premiums haven鈥檛 gone up too much on average in the first two years of the marketplaces, but that could change. The federal government has been protecting insurers from unexpectedly high medical bills, but that cushion disappears after next year. At the same time, insurers finally have enough experience with their initial customers to figure out if their premiums are sufficient to cover medical costs. If they鈥檙e not, expect increases.
Affordability. People who get their insurance through their employer have mostly been spared jolts from the health law. But the federal government begins taxing expensive health plans in 2018. The 鈥淐adillac tax,鈥 created by the health law, will pressure employers to offer skimpier health coverage or pass the taxes鈥 cost on to their employees. Also, individuals buying their insurance on the health law marketplaces continue to risk large out-of-pocket costs if they need lots of care. Their maximum financial obligations for next year are $6,850 for individuals and $13,700 for families. Those who choose to go out of their insurance network may have no ceiling on how much they may have to pay.
Political Resistance. Thursday鈥檚 ruling did little to diminish the GOP鈥檚 zeal to repeal the health law. Republicans on both sides of the Capitol pledged to continue their efforts to kill the ACA. A by House Republicans last year alleges the president overstepped his authority when implementing the health law. The topic remains grist for the 2016 presidential campaign, with several Republican presidential candidates 鈥 including , and former — reiterating their desire to repeal the law. If the Republicans capture both the White House and Congress in 2016, all bets are off over whether the law survives intact.
Kaiser Health News writers Julie Appleby, Mary Agnes Carey, Phil Galewitz and Jordan Rau contributed to this report.
