There was widespread concernwhen the mandate was repealed that the result would be a wave ofyounger and healthier Americans exiting the ACA markets. (Photo:Shutterstock)

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Whatever flaws the Affordable Care Act (ACA) may have, itappears that it can take a punch.

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A new study by the Kaiser Family Foundation (KFF)finds that despite the repeal of the ACA's individual mandate,premiums remained largely stable in 2019, easing fears that thesystem would enter a "death spiral" caused by enrollees leaving themarket.

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Related: How uncertainty over ACA is affecting healthcare

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"Results from the first nine months of 2019 suggest that theindividual market remains profitable and stable despite theeffective repeal of the individual mandate," the report said."Continued modest growth in claims costs and a decrease inhospitalizations through the third quarter of 2019 indicate thatthe repeal of the individual mandate penalty and expansion ofshort-term insurance plans did not leave the individual marketsignificantly less healthy."

Trump administration tries, tries again

The Trump administration has pursued a number of strategies to"reform" the ACA, also known as Obamacare, after a failed attemptat repealing the law entirely in 2017. The health care law has longbeen criticized by Republican politicians, and repeal of the law soclosely associated with Barack Obama was one of President Trump'stop priorities.

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But the ACA has proven to be surprisingly resilient. Attempts toweaken the market through cutting back programsto sign up new enrollees, creating work requirements for Medicaidrecipients, and promoting alternative insurance models have movedforward through various executive orders and rule changes byfederal agencies. Yet none of those efforts have had much effect onthe ACA markets overall.

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The repeal of the individual mandate, which was included in a2017 tax reform bill, was the most serious challenge to Obamacareso far. The ACA's individual mandate required any American who didnot purchase coverage to pay a tax penalty—a measure that was aimedat providing more incentive for people to purchase coverage andtherefore create larger, more financially stable insurancepools.

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There was widespread concern when the mandate was repealed thatthe result would be a wave of younger and healthier Americansexiting the ACA markets. This would leave sicker, more expensivepatients in the market and result in increasingly higher premiums,which would not be sustainable.

It turns out people like having insurance

The death spiral has not happened so far, according to the KFFreport. According to the report, at the end of 2018, ACA insurancepremiums had risen about 5 percent as a result of the individualmandate's repeal.

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But the report found that premiums were largely steady in 2019,in part because insurers priced plans too high in 2018. "Despiteconcerns about the continuing impact of the loss of the mandatepenalty, the individual market has remained fairly stable through2019. Enrollment among those not eligible for subsidies declined by10 percent in early 2019, but individual market enrollment overallappears to be stabilizing, with total market enrollment falling byjust 5 percent," the report said.

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However, the ACA marketplace is not indestructible, and thereare still areas of concern. The KFF report noted that rural areasof the country are "fragile," with fewer carrier options and higherpremiums than urban areas. And an analysis by Vox noted that while ACA enrolleeswho qualify for subsidies are shielded from premium increases,those with higher incomes are struggling to afford rising premiumcosts.

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"The subsidized customers are partly or fully protected frompremium hikes, so they kept signing up," the Vox analysis said. "Itwas the unsubsidized customers, people making 400 percent of thefederal poverty level or more, who faced the full brunt of thoseincreases." This resulted in some enrollees leaving themarketplace, but overall the KFF study found the ACA market to bestable.

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"Some insurers exited the market in previous years, but othershave been successful and expanded their footprints, as would beexpected in a competitive marketplace" the report concluded."Marketplace premiums are decreasing by 2 percent to 3 percent onaverage in 2020, further indicating that insurers expect theindividual market to remain stable. Marketplace enrollment for 2020is generally steady."

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Next up for attempts to end the ACA: a lawsuit that says the lawis unconstitutional, since the individual mandate no longerprovides a tax framework as part of the law. That complicatedproposition is working its way through the courts and islikely to end up in the Supreme Court.

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