"Right now (Democrats) can't criticize the ACA. It's just not politically smart," said Dan Mendelson, chief executive of the consulting firm Avalere Health
who oversaw health programs at the Clinton administration's Office of Management and Budget. But should Obama win a second term and Democrats retain
control of the Senate, "I think that adjustments are on the table" as part of a larger deal to reduce the federal deficit, he said.
Scale Back Subsidies:
As part of that effort to reduce federal spending, there could be pressure to scale back the health law's subsidies that help low-income residents afford
coverage. People who earn up to 400 percent of poverty - currently about $92,000 for a family of four - are eligible to get financial help in purchasing
coverage. Another big-ticket item is the expansion of Medicaid coverage to anyone up to 133 percent of the poverty level, or about $30,656 for a family of
The ACA is "so vast that by default it has to be impacted if there is a bipartisan, grand bargain debt deal," said Mike Tuffin, managing director of the
consulting firm APCO Worldwide's Washington, D.C., office and formerly executive vice president of America's Health Insurance Plans, an insurance industry
trade group. "You can imagine the subsidies being impacted, the Medicaid expansion being impacted."
Changing the law's implementation schedule is wishful thinking among Republicans, Mendelson said. Any delay in full implementation could risk political
backlash from consumers, who have waited years for the major provisions of the ACA to kick in. Delays may also open the law to other changes that Obama and
Democrats don't want.
"My feeling is that it would be a major political liability for the president to encourage delay," he said, "and that if this is going to
be his legacy, I see no indication from the policy makers that they either want or expect there to be a delay."
The president "is willing to work with anyone with good ideas to improve the Affordable Care Act. What he is not willing to do is reopen old partisan
battles over the central guarantees of Obamacare," said Adam Fetcher, a spokesman for the Obama campaign.
Change in Age Rating Bands: The ACA prohibits insurers from charging more than three times as much for a policy sold to an older person than to a younger person. (This does not affect
people over 65 who are covered by Medicare.) This is a change from current law in most states where there are no limits on how much more insurers can
charge older people. America's Health Insurance Plans is advocating that the law's rating bands be changed to 5:1 to prevent what the group describes as "rate shock" for
younger people and families.
The issue that arises is that the law "makes coverage more affordable for the elderly but more expensive for the young people they want to buy coverage,"
said Paul Heldman, senior health policy analyst with Potomac Research Group, a Washington research firm.