Republicans have adapted, too. In January, three Republican senators unveiled a “repeal and replace” alternative called the Patient Choice, Affordability, Responsibility and Empowerment (CARE) Act. The overhaul eliminates or reduces most government mandates while offering tax credits to help lower-income people buy insurance. The proposal limits the tax exclusion for insurance offered by employers and permits insurers to charge more for preexisting conditions if beneficiaries do not maintain continuous coverage.

In February, the Obama administration responded to sustained pressure from the business community by delaying the ACA’s insurance mandate for employers with 50 to 99 workers until 2016. The news revived a Republican talking point that the law unfairly postpones rules for businesses but not individuals.

Push to Curb ED Visits by New Medicaid Beneficiaries

Backers of the ACA have argued that improved access to health care might decrease emergency department visits by new Medicaid beneficiaries. Experts, however, have warned of an increase in ED visits—at least initially—and the Centers for Medicaid & Medicare Services recently released guidelines designed to mitigate any uptick in unnecessary visits.

Among the agency’s three main strategies: focusing on “super-utilizers” through services like health homes and on-site ambulatory clinics, increasing access to primary care, and using more targeted interventions for patients with behavioral health issues.

Several experts told Modern Healthcare they were unimpressed with the guidelines, citing a lack of new ideas and insufficient attention to mental health. Meanwhile, a study in the journal Science added fuel to the fire by finding that new Medicaid beneficiaries in Oregon significantly increased their visits to the ED and to other care providers during their first 18 months of coverage.

Why? Economists told The New York Times that patients may be accessing ED services more often as Medicaid reduces their upfront costs. Experts have hotly debated whether this higher usage will persist and whether it also reflects a lack of primary care access. The heightened demand could put more strain on the nation’s emergency physicians, though the overall financial impact may be more limited. In 2010, a government report found, total ED visits represented only 4 percent of total U.S. health care spending.

Bryn Nelson is a freelance medical journalist based in Seattle.