Many portions of the Affordable Care Act are very popular, and the law has survived multiple repeal efforts by Congress and President Trump. Despite this, the ACA is still very vulnerable to sabotage. The Trump administration has actively engaged in that sabotage, as have many other Republicans at the state and federal level. However, the ACA’s popularity and fears of being blamed for a marketplace collapse have put conservative lawmakers in a very precarious position—leading some to take actions that could strengthen the law, while at the same time endorsing efforts to dismantle it.

An overarching problem for state and federal lawmakers who have been vocal in calling for the ACA’s repeal is that the parts of the law that are most vulnerable to sabotage are also the most centrist and most important to their voters. As a result, those policymakers find themselves caught between pressure to support the Trump administration’s ACA sabotage efforts and pressure from constituents who benefit from the Marketplace and the ACA consumer protections.

When we use the term “sabotage” in the context of the ACA, we are referring to a wide range of tactics that destabilize the ACA insurance Marketplace either by increasing costs for insurers and premiums for participants, which causes fewer healthy people to sign up, or by creating greater uncertainty and risk for insurers. The ACA sabotage has included things like ending funding for some of the insurance subsidies, creating barriers to signing up for Marketplace plans, and filing lawsuits or introducing bills that create more uncertainty and cause insurers to  consider dropping out of the Marketplace altogether. These tactics are boosting premiums and reducing choices for kids and families in Wisconsin—ultimately making health care less accessible.

Wisconsin’s reinsurance plan for the Marketplace illustrates how state policymakers are taking inconsistent actions as they try to protect some aspects of the ACA (or dodge blame for premium increases), even as they continue to support sabotage that causes or exacerbates the problems. Governor Walker recently pushed a reinsurance bill through the legislature that will spend about $200 million a year to insulate insurers from some of the expense of their high-cost patients. Reinsurance can be an effective tool for stabilizing insurance markets and holding down premiums, which is why insurers and providers supported the plan. Yet the benefits of reinsurance will be outweighed by ongoing sabotage efforts that increase risks and costs for insurers. Rather than opposing the sabotage, the Governor has abetted it by doing things like authorizing the state Attorney General to participate in a recently-filed lawsuit against the entire ACA.

Over the next couple of months, Kids Forward will examine and explain what’s at stake for Wisconsinites in the ongoing changes to the ACA. For example, we will analyze enrollment trends in the ACA Marketplace and which parts of the state get the largest Marketplace subsidies. We will also summarize some of the significant effects of the efforts to undermine the law. But for now, we want to look a little more closely at a few of the reasons why the efforts to sabotage the law put conservative lawmakers in a difficult position, especially in Wisconsin:

• The ACA Marketplace is the centrist core of the law. The idea of expanding access to private insurance through a subsidized marketplace was developed with the help of conservative think tanks and was the core of the Massachusetts plan, sometimes referred to as “RomneyCare,” which was a model for the ACA.
• Governor Walker used the subsidized Marketplace to justify sharply cutting BadgerCare eligibility. Governor Walker and other Wisconsin Republicans embraced the Marketplace idea and used the existence of that potential source of subsidized coverage as a key argument for ending BadgerCare eligibility for more than 60,000 parents with income between 100% and 200% of the federal poverty level. The state made that change to BadgerCare in 2014 when the Marketplace began.
• Sabotage hurts higher income Marketplace participants the most. Purchasers of Marketplace plans who have income between 100% and 400% of the poverty level are eligible for premium tax credits, and those credits have largely insulated more than four-fifths of Marketplace participants from the rising cost of premiums that has resulted from various forms of ACA sabotage. But the rapid increase in premiums is very costly for people in the Marketplace who have income that is more than four times the poverty level (which is $65,840 for a married couple with no children or $100,400 for a couple with two children). Many of the people whose premiums increase are likely to be Republicans.
• Sabotaging the Marketplace will also undermine popular consumer protections in the ACA. The actions that have been driving up premiums and destabilizing the ACA Marketplace are intertwined with efforts to directly or indirectly take away some of the law’s consumer protections. For example, one of the latest forms of sabotage is to redefine and expand sale of short-term insurance plans, which can deny people based on pre-existing conditions, charge women more than men, are not required to cover essential health services like mental health and prescription drugs. By substantially expanding that relatively unregulated portion of the insurance industry, fewer healthy people will buy Marketplace plans, premiums will increase, and the economic viability of the Marketplace will be at a greater risk.

For all of those reasons and more, it’s easy to see why some of the politicians who have attacked the ACA would be concerned that they may take the blame if premiums rise significantly or if the Marketplace collapses and the consumer protections are rolled back. That helps explain why some ACA opponents are now backing measures like reinsurance that could potentially help stabilize the Marketplace. Nevertheless, it’s hard to understand how a governor would authorize the state’s participation in another lawsuit attacking the ACA at its core—less than 24 hours before signing the bill to help insurers and potentially help stabilize Marketplace insurance.

Jon Peacock and William Parke-Sutherland