The Affordable Care Act has survived its most critical political test with the failure of the GOP’s American Health Care Act. Schisms within the Republican Party belied the truth that Republicans were never serious about replacing President Obama’s signature domestic policy achievement.
But the danger is far from over: While the ACA won’t “explode,” to borrow President Trump’s favorite term, the new administration can let it rot on the vine. If Trump ignores the hard work of keeping millions insured, he will have no one but himself to blame.
When President Obama signed the ACA in the spring of 2010, the tough slog of legislating was replaced by the monumental task of overhauling the nation’s health care system. As the director of intergovernmental and external affairs at the Department of Health and Human Services, I spent years on the front lines of implementing Obamacare. Here are the lessons I learned, and areas where this administration can either step up and serve its constituents, or drop the ball and imperil America’s health care system:
1. Communication is key. One of the most important ways HHS can raise awareness of the Health Insurance Marketplace is through paid media. Millions of Americans saw television or online advertising directing them to Healthcare.gov. While not everyone liked the changes the ACA brought, we tried our best to make sure everyone knew those changes were coming and what it could mean for them.
When, in its first days, the Trump administration pulled down advertising that had already been paid for, just days before the end of the enrollment period, the number of people who signed up fell thousands short of expectations. It is clear, from the GOP’s failure to pass a bill, that Republican promises of replacing the ACA were little more than lip service. The party has never communicated its own ideas on health care in a coherent way, and the thousands who didn’t sign up for health care in January ― and the millions left unsure of what possible changes could mean for their coverage ― will pay the price.
2. Partner up. The Obama administration reached far beyond traditional advertising to attract new people into the insurance market. Some people saw ObamaCare messages on their LinkedIn pages, or got a Lyft discount code to go enroll. Utility companies, pharmacies, health care providers, and so many others all worked to promote enrollment.
Building and maintaining those relationships requires hard work. A new president who prides himself on making deals and striking up relationships could do wonders in helping extend the message of health care enrollment to new corners of America ― or he could abandon productive deals already bearing fruit.
3. All politics is local. The successful functioning of the federal marketplace requires intensive, hands-on, retail efforts. HHS, the Centers for Medicare and Medicaid Services and the White House spent countless hours on the phone and in person meeting with insurance companies and states to encourage their participation, hear their feedback, and have an ongoing dialogue about the Marketplace.
Without a willing partner in the government, and with the ongoing uncertainty created by the Republican Party’s abject failure to offer a coherent alternative, insurers are much more likely to drop their participation. Ironically, that would exacerbate the Republicans’ biggest objection to the ACA: that it limits choices for consumers and imperils the future of the Marketplace.
4. The devil is in the details. Those of us who have worked on reforms ― and here I include even the Republicans who worked on their own alternative ― knew that health care was complicated, apparently long before the president did. The Secretary of HHS and CMS Administrator oversee dozens of little-known but critical provisions of the ACA that affect one-third of the nation’s economy, and failure to properly implement these provisions could severely weaken the Marketplace.
HHS Secretary Tom Price spent his time in Congress railing against the ACA. He is now responsible for upholding the law, and he can use his power to extend health coverage to millions more Americans ― if he puts in the work necessary to do so.
If Trump and Price want the Affordable Care Act to fail out of some misplaced desire for political gain, they have the power to make it so. But if they weaken or kill the Marketplace and millions lose coverage, the blame will lie squarely on their shoulders.