In 2017, no issue disappointed employers and their advocates more than healthcare. It all started last November. An upstart candidate won the presidential election, running, among other things, on the promise to “repeal and replace” the Affordable Care Act (ACA). Now, a year later, very little has actually changed.

Sometimes, industry leaders have to acknowledge missed expectations when they see them. In 2017, some HR departments fell short. But it’s not always employers themselves that disappoint; much of the time, organizations can’t advance major improvements due to legislative stagnation. 

“It's incredible to think that with all that was discussed, deliberated and debated with healthcare reform in 2017, virtually nothing changed on the legislative front,” said Shandon Fowler, founder and principal of Four8 Insights. 

How we got here

Wholesale reform of the individual healthcare insurance market is a very controversial animal that deserves its own conversation, but what employers wanted most out of the Republican Party’s reconciliation efforts came down to a relatively short list of proposals:

• Repeal the employer mandate;
• Roll back, delay or otherwise repeal the ‘Cadillac’ tax;
• Remove federally mandated caps on employer contributions to employees’ health savings accounts (HSAs); and
• Get rid of taxes on medical devices and other healthcare elements.

And, perhaps most importantly, to do all of this without shifting the responsibility to pay for lapses in the individual market with a tax on employers. Moreover, the reconciliation bill was merely a first step in a more exhaustive process. The GOP had majorities in two houses with which to get the job done.

So what happened?

The short answer is: not enough votes — at least in the Senate. House Republicans were eventually able to pass the American Health Care Act (AHCA), but observers knew from the get-go that the party’s leaders in the Senate would craft their own version.

Chart

How Key Senate GOP Members Voted

GOP Senator

BCRA

BCRA Better Care Reconciliation Act

ORRA

ORRA Obamacare Repeal and Reconciliation Act

Skinny repeal

Graham-Cassidy

Graham-Cassidy bill The Graham-Cassidy bill was never officially brought to a vote; responses in this column are based on reports from Politico.

Alexander

TN

Capito

WV

Collins

ME

Corker

TN

Cotton

AR

Graham

SC

Heller

NV

Lee

UT

McCain

AZ

Moran

KS

Murkowski

AL

Paul

KY

Portman

OH

Credit: The New York Times and POLITICO
Visualization: Natalie Forman/Industry Dive

“The ACA is popular at many levels,” Andrew Cavenagh, founder and managing director of Pareto Captive Services, told HR Dive. “Lots of people agree that the ACA is too expensive but no one wants to take away coverage and once someone has it, it’s incredibly difficult to remove.”

Reform of the individual market dominated headlines and spawned vigorous arguments at Congressional town halls. Even employer advocates had trouble accepting the instability in which GOP proposals would leave the ACA’s public exchanges. That’s what doomed the succession of Senate proposals that began with the Better Care Reconciliation Act (BCRA).

It’s hard to see a way for legislators to break the deadlock without bipartisanship, Fowler said. “Otherwise, the closest we'll get to healthcare reform in 2018 is another round of Executive Orders.”

But the circus of media headlines clearly isn't proving a reliable source of change for employers and the employees who depend on them for coverage. That’s why Cavenagh and others suggest their attention be turned toward more practical solutions.

"ACA and the subsequent repeal efforts are not really healthcare reform — they are health insurance reform and within health insurance, they focused very heavily on the individual and Medicaid populations," Cavenagh said. "If you want employers on board, find ways to reduce the cost of healthcare. If you lower the costs, employers will expand coverage, with or without regulations."