"WASHINGTON — The Affordable Care Act was conceived as a mix of publicly funded health care and privately purchased insurance, but Republican attacks, culminating this month in the death of a mandate that most Americans have insurance, are shifting the balance, giving the government a larger role than Democrats ever anticipated.
And while President Trump insisted again on Tuesday that the health law was “essentially” being repealed, what remains of it appears relatively stable and increasingly government-funded.
In short, President Barack Obama’s signature domestic achievement is becoming more like what conservatives despise — government-run health care — thanks in part to Republican efforts that are raising premiums for people without government assistance and allowing them to skirt coverage.
By ending the tax penalty for people who do not have coverage, beginning in 2019, Republicans may hasten the flight of customers who now pay the full cost of their insurance. Among those left behind under the umbrella of the Affordable Care Act would be people of modest means who qualify for Medicaid or receive sizable subsidies for private insurance.
“Republicans have inadvertently strengthened the hand of Democrats like me who prefer richer subsidies to a mandate and welcome the expanded federal role that will come with those subsidies,” said Joel S. Ario, a former insurance commissioner from Pennsylvania who worked in the Obama administration.
In days, the Trump administration is expected to carry out an executive order with proposed rules that would allow people to buy less expensive — and less comprehensive — coverage, through either business and professional associations or short-term private policies.
The Affordable Care Act’s success in reducing the number of uninsured owes more to Medicaid than to private health insurance. About 75 million people are now enrolled in Medicaid, a number that has increased by about one-third since the adoption of the Affordable Care Act. A smaller number, about 10 million, buy coverage from private insurers through the health law’s marketplace.
Among people ages 18 to 64, the proportion with private health insurance coverage is about the same today as in 2005, according to the National Center for Health Statistics. But the proportion with public insurance coverage has increased to more than 19 percent, from 11.5 percent in 2005, and the share of people in that age range who are uninsured has fallen to 12.5 percent, from about 19 percent.
In total, more than one-third of the population is covered with federal assistance, through Medicare, Medicaid, the Department of Veterans Affairs, the military and Affordable Care Act subsidies. (And that does not include the larger group of people who benefit from tax subsidies for health insurance provided by employers.)
Mr. Trump and Republicans in Congress failed this year in their efforts to cut Medicaid and could try again in 2018. Speaker Paul D. Ryan said this month that Republicans would try next year to slow the growth of federal health spending because “it’s the health care entitlements that are the big drivers of our debt.”
But Senator Mitch McConnell, the majority leader, has been leery of another run at health care in an election year, and it is possible that Medicaid could, in the near future, actually grow further under the Affordable Care Act. Maine voters approved a referendum last month to expand Medicaid in that state, though Maine’s Republican governor, Paul R. LePage, is dragging his feet. Mr. LePage will not be on the ballot in November, when the state could elect a governor more willing to accept the referendum’s results.
The governor-elect of Virginia, Ralph S. Northam, has vowed to expand Medicaid and could have an evenly split House of Delegates, depending on the outcome of a drawing of lots this week that will decide the winner of a tied race in southeastern Virginia.
A Democratic wave election in November could also shift the balance of power in a few other state capitals."
Years of Attack Leave Obamacare a More Government-Focused Health Law - The New York Times
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