I read your post about open enrollment for the ACA and was hoping you might expand on why you believe it would take years to dismantle. I've been terrified that with a Republican house/senate, Trump could just snap his fingers and make it go away within months of taking office. I'd love some reassurance that that's not possible.

Hiya, sure I can share some thoughts on the matter! First, it's very important to understand the ACA is a huuuuuuuuuuuuge system with subject matter experts in dozens of places throughout the process. I'm one of those SMEs, but I am at the end of the process where the revenue is generated, so my insight is limited on the public facing pieces.

What this means is that I am professionally embedded in the ACA in a position that exists purely to show what conditions people are treated for and then generate that data into what's called a "risk score". There's about 6 pages I could write on it, but the takeaway is that the ACA is

1) intricately interwoven with the federal government

2) increasingly profitable, sustainable, and growing (it is STILL a for-profit system if you can believe it)

3) wholeheartedly invested in by the largest insurance companies in the country LARGELY due to the fact that they finally learned the rules of how to make the ACA a thriving center of business

4) since the big issuers are arm+leg invested in the ACA, there is a lot of resistance politically and on an industry level to leave it behind (think of the lobbyists, politicians, corporations that will fight tooth and nail to protect their profit + investment)

The process to calculate a risk score takes roughly 2 years. There is an audit for the concurrent year and then a vigorous retro audit for the prev year - - this is a rolling cycle every year. Medicare has a similar process. These are RVP + RADV audits if you would like the jargon.

Eliminating the ACA abruptly is as internally laughable as us finishing the RADV audit ahead of schedule. If Trump were to blow the ACA into smithereens on day 1, he would be drowning in issuer complaints and an economic health sector that is essentially bleeding out. You cut off the RVP early? We have half of next RADV stuck in the gears now. You cut off the RADV early? No issuer will get their "risk adjusted" payments for services rendered in the prev benefit year (to an extent, again very complex multi-process system).

The ACA is GREAT for the public and should be defended on that basis alone. However, the inner capitalistic nature of the ACA is a powerful armor that has conservatives + liberals defending it on a basis of capital + market growth. It's not sexy, but it makes too much money consistently for the system to be easily dismantled.

Or at least that's what I can tell you from the money center of the ACA. they don't bring us up in political conversation because we are confusing to seasoned professionals, boring to industry outsiders, and consistently we are anathema to the anti-ACA talking points.

I am already preparing for next year's RVP for this window of open enrollment. That RVP process will feed into the RADV in 2026. In 2025, we begin the RADV for 2024. If nothing else, the slow fucking gears of CMS will keep the ACA alive until we finish our work at the end of the process. I highly doubt that will be the only reason the ACA is safeguarded, but it is a powerful type of support to pair with people protecting the ACA for other reasons.

I work every day to show, defend, and educate on how many diagnoses are managed thru my company's ACA plans. My specialty is cancer and I see a lot of it. The revenue drive comes from the Medical Loss Ratio (MLR) rule stating only 20% MAX of profit may go to the issuer + the 80% at a minimum must go back to the customer or be invested in expanding benefits. The more people on the plan using it, the higher that 20% becomes for the issuer and the more impactful that 80% becomes for the next year of benefit growth. It is remarkably profitable once issuers stop seeking out "healthy populations". The ACA is a functional method for issuers to tap into a stable customer base (sick/chronic ill customers) that turns a profit, grows, and builds strong consumer bases in each state.

The industry can never walk away from this overnight - - this is the preferred investment for many big players. Changing the direction of those businesses will be a monumental effort that takes years (at least 2 with the audits). In the meantime, you still have benefits, you still have care, and you still have reason to sign up. Let us deal with the bureaucracy bullshit, go get your care and know you have benefits thru 2025 and we will be working to keep it that way for 2026 and forward. This is a wing of the federal government, it is not a jenga tower like Trump wishes.