With Donald Trump headed to the White House and his party firmly in control of Congress, Republicans will finally have a chance to prove what they've been saying all along: that they can produce a better version of healthcare reform than the Affordable Care Act.
It's clear that the ACA is as imperiled as it has ever been. Trump has fervently vowed to repeal it--and with Republican control of both chambers of Congress, he may well get his wish. After all, the law’s most visible component, the exchanges, are on shaky ground as it is, with premiums rising and some health insurers retreating from the marketplaces.
Plus, President Barack Obama’s last attempt at convincing Republicans to work on fixing the ACA--not repealing it--fell on deaf ears even before the party’s resounding victory Tuesday.
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What gets lost in all the talk about the ACA’s uncertain future, though, is the fact that while some insurers have struggled to make a profit in the individual marketplaces, there are other aspects of the law to which they have become quite attached.
Take Medicaid expansion, an idea championed by Democrats (and even once embraced by Vice President-Elect Mike Pence) that has been a boon to insurance companies in the form of lucrative managed care contracts. Some companies that specialize in slimmed-down Medicaid plans have also thrived on the exchanges where others have floundered.
Then there’s the ACA’s provisions that encourage the transition to value-based payments, which insurers have embraced and largely retooled their business models to reflect. Accountable care organizations, for example, have sprung up like wildfire, producing promising results for some companies.
A wholesale repeal of the ACA would also erase the law’s historic gains in reducing the uninsured rate. Though many of the newly insured have turned out to be costlier to cover than expected, such a move would still rob insurers of millions of new customers.
The question, then, becomes what will replace the law--and that’s where it gets interesting.
Trump has a plan, but it is short on details. Perhaps most visibly, he has advocated for selling insurance across state lines--a timeworn GOP talking point that many experts agree is not feasible. He would also repeal Medicaid expansion and convert Medicaid federal matching funds into a block grant, the latter of which would drastically cut Medicaid funding and coverage.
One analysis from The Commonwealth Fund says that his plan could add nearly 20 million people to the ranks of the uninsured, and even more if his Medicaid proposals come to fruition.
For those worried about the great unknown, though, know this: Trump won’t be alone in redefining healthcare policy in America, a fact he clearly acknowledges in his own policy platform by saying, “any reform effort must begin with Congress.”
In fact, campaign rhetoric that was short on coherent policy ideas and long on hyperbole is about to fly smack in the face of policymaking realities. Even with Republican control of Congress, a viable ACA replacement will require a lot of work, a lot of coordination with the healthcare industry, and yes, a lot of compromise.
Just look at House Speaker Paul Ryan’s own ACA replacement plan, which leans on tried-and-true Republican proposals such as greater use of health savings accounts--but also suggests policies that look an awful lot like parts of the law it’s trying to replace.
For example, it promises to maintain the ban on denying coverage to those with pre-existing conditions and allow young adults to stay on a parent’s insurance plan until age 26.
There would still be exchanges, with qualifying individuals getting an age-adjusted tax credit to use in the individual market. And there would still be some form of an open enrollment period for the uninsured.
Perhaps more concerning, though, is the seemingly promising proposal of creating high-risk pools--an idea that experts noted has been tried before and has led to high administrative costs, unaffordable premiums and skimpy benefits. Indeed, argued the left-leaning Center for American Progress, high-risk pools would "quarantine people who are old and/or sick in separate, more expensive and unsustainable markets.”
That said, the word “unsustainable” has been thrown around a lot by insurance executives in earnings calls lately, in describing the exchange markets created by our current iteration of healthcare reform. So certainly they--and judging by the outcome of the election, many Americans--believe there is much room for improvement.
Now it’s the Republicans’ turn to do it better than the Democrats have.
So far, it looks like what they are offering is either more of the same or old, dubious ideas. But for the sake of the millions who rely on the protections the ACA has provided and an industry that has largely embraced it, here’s hoping that prediction, like so many others this election season, is proven wrong.