Wednesday, July 3, 2013
The Affordable Care Act has largely weathered its challenges in court, but its political vulnerability continues to result in erosion of the Act's provisions.
The provisions for long-term care were abandoned two years ago, many state legislatures and governors are balking at the Medicaid expansion, and now the Obama administration has delayed implementation of the employer mandate to offer health care coverage.
To be sure, glitches are to be expected with major legislation such as the Affordable Care Act. Many states were slow to adopt the original Medicaid program, and it took a decade to take food stamps nationwide. In the end, we may see an Affordable Care Act whose key provisions remain intact.
Still, the history of health care reform efforts give reason for concern. Health care rights have been unstable in the United States to the extent that they adopt different approaches for rich and poor. Thus, while Medicare has provided a reliable guarantee of coverage because it covers all seniors, Medicaid has not provided adequate access to health care because it relies on the willingness of wealthier Americans to fund a program that does not benefit them.
The Affordable Care Act looks much more like Medicaid than Medicare. Prosperous Americans will continue to receive private health care coverage from their employers, while low-income Americans will have to rely on Medicaid or on federal subsidies to purchase private coverage. Over time, it is not clear how willing wealthier people will be to maintain funding at adequate levels for Medicaid or the subsidies.