What’s next for the ACA? A roundup of early predictions

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© 2010 Legosz, Flickr | CC-BY | via Wylio

Summary: No one really knows what will happen when Donald Trump takes office, in light of his pledge to repeal the Affordable Care Act. Nothing is as simple as it sounds ever in life; also, Trump will have to contend with the fact that many parts of the A.C.A. were wildly popular with insurance companies, hospitals and other providers, big drug companies and a host of other health care market players who profited from it. Also, it’s wise to recall that health spending has been an engine of the economy; health stocks have boomed, by and large, and health sector jobs have risen consistently for a number of years. So, what will happen? Prognostications abound. Here are some, selected from post-election writings by people who have reason to make wise predictions about the future. But we won’t really know until the new president and congress take their seats in January. So: Fasten your seatbelts.


First, this “Oh shit, what should I do before January” document has been circulating around the Web. Crowdsourced by multiple people, it is reportedly going to be placed onto a wiki somewhere on the web.

 

Kaiser Health News

 

The Affordable Care Act transformed the medical system, expanding coverage to millions, injecting billions in tax revenue, changing insurance rules and launching ambitious experiments in quality and efficiency. …

 

Less of that might disappear under President-elect Donald Trump’s pledge to “repeal and replace Obamacare” than many believe, policy analysts say. Republicans promising change might not quickly admit it, but in some respects Obamacare’s replacement may look something like the original.

 

“It gets into questions of semantics,” says Mark Rouck, an insurance analyst for Fitch Ratings. “Are they really repealing the act if they replace it with new legislation that has some of the same characteristics?”

 

Problems that helped give rise to the health law — rising costs, an aging population, mediocre medical results — haven’t gone away. The ACA pushed insurers, hospitals and employers to launch their own reimbursement reforms, which are largely unaffected by who runs Washington.

 

Even fierce health-law opponents may pause at the political risk of taking benefits from millions who gained coverage since its implementation. Subsidies for the middle class to buy insurance may remain — even if they’re not the Obamacare tax credits applied through online marketplaces, says Joseph Antos, a health economist at the American Enterprise Institute.

 

“The idea that they’re just going to wipe that money away is pretty unlikely,” he says. “They don’t want to be in a position of saying they’re just kicking millions of people out in the street.”

 

Others disagree.

 

“I think they go away,” says Ana Gupte, a health care analyst for Leerink Partners. “The subsidies … are at risk” along with the ACA’s requirement that everybody have health coverage, she says.

 

Topping the list of ACA provisions likely to survive under Trump is the requirement that employers cover workers’ children up to the age of 26, analysts say. The measure is widely popular and not especially expensive.

 

Dan Goldberg, Politico New York:

 

What becomes of Republican plans to replace the Affordable Care Act may well rest in the strategy laid out by New York’s senior senator.

 

Charles Schumer, almost certain to become Senate minority leader in 2017, will have enormous sway over whether his caucus chooses to work with President-elect Donald Trump and his allies, or takes a page out of the Republican playbook and obstructs for as long as possible….

 

It’s a near certainty that Schumer and his caucus will oppose the repeal effort, particularly if the Republicans do not have a replacement plan ready to go. Republicans already are squabbling over how quickly a repeal effort should move ahead.

 

Senate Democrats can filibuster any Republican plan, and it is an open question as to whether the Republicans can accomplish all their health care goals through reconciliation, a parliamentary move that would skirt the filibuster, and one that requires Republicans and the White House to agree on a budget.

 

The question consuming the health care sector is whether there is any replacement plan that could plausibly bring along a meaningful number of Senate Democrats without alienating House Republicans. And even if Ryan and McConnell were to move to the center while somehow keeping their own caucuses in line, might Schumer find Trump and the Republicans more useful as a foil than as friend, as McConnell dealt with Obama?

 

“Is it better to let it burn?” Howard asked. “It would give the Democrats a cudgel with which to beat Republicans for the next couple of years.”

 

For now, Schumer is keeping his options open, going so far as to say he believes an obstructionist party will pay a political price in 2018, when Senate Democrats must defend 25 seats. About half of them are in states that voted for Trump or where Trump narrowly lost. (Republicans will be defending just eight Senate seats in 2018.) …

The wild card, everyone agrees, is Trump, a man who prides himself on his deal-making skills and has a long history with Schumer.

 

He may be more amenable to offering Schumer and Democrats liberal goodies such as infrastructure money in exchange for fixing the law.

 

“At the end of the day, he is a New Yorker and so is Schumer,” Parente said. “They are of the same cloth. When things get rough, there could be a dinner between Trump and Chuck where one says ‘our airports are crap, let’s make LaGuardia a museum and move on.’” …

 

“Health policy is back in a very big way,” said Karen Ignagni, who helped Obama pass the ACA when she led AHIP, the health insurance lobby.

 

Ignagni now leads EmblemHealth, which offers insurance plans on the individual market, the small business market, as well as Medicaid plans and an Essential Plan.

 

“Insurance companies will prioritize the stability of their markets,” Ignagni said. “There are a number of people in Congress, on a bipartisan basis, who support guaranty issue,” she said. “The experience in the states is that without a [mandate], guaranty issue doesn’t work.”

 

Nicholas Bagley, The Incidental Economist

With the caveat that this is a bad week for predictions, I’d like to offer my thoughts on what might happen next to the Affordable Care Act. …

 

For starters, I doubt that Republicans will be able to coalesce around an alternative to Obamacare. They’ve demonstrated time and again that they can’t get past the white-paper stage. The reason is simple: health policy is hard. There are winners and losers and extending coverage to the uninsured costs a bunch of money.

 

Democrats barely managed to pass health reform in 2010 even though they cared passionately about it. The Republican Party has never cared much about expanding coverage. There’s no reason to think Republicans care enough this time to get their restive membership on board with a replacement, especially since Donald Trump is unlikely to make health reform a priority. Just a few defections in the Senate and a new bill is toast.

 

So no replace, at least not yet. But what about repeal? On this, I think the Republicans will press forward. Every single Republican in the House and Senate (except Susan Collins) has already voted for a reconciliation bill that eliminates the individual mandate, the subsidies, and the ACA’s new taxes. They can use that as a template to wipe the ACA’s most controversial provisions from the books.

 

At the same time, Republicans would have a ready excuse for keeping some popular parts of the law, most of which aren’t subject to reconciliation because they don’t affect spending or revenue. They include rules about preexisting conditions, lifetime and annual caps, allowing young people to stay on their parents’ insurance, and zero cost-sharing for preventive care.

 

But wait a minute. Wouldn’t the reconciliation bill unravel the individual market? Won’t Republicans be skittish about repeal if they can’t do replace?

 

I don’t think so. You’ve got to bear in mind that passing the reconciliation bill would represent an immediate $346 billion tax cut over ten years to the wealthy—$123 billion from the Medicare tax surcharge and $223 billion from the tax on investment income. All of that money—every dime—will go to people making more than $200,000 a year. However ambivalent Republicans may be about health reform, they are not at all ambivalent about big tax cuts to the wealthy. …

 

Besides, the Republicans can and will delay the day of reckoning. Already, the reconciliation bill doesn’t kick in until 2018. It’d be child’s play to extend that to avoid a collapse of the insurance markets right before the midterm elections. Republicans would then get to take credit for repealing Obamacare without pitching millions off their plans. It’s a neat trick.

 

Sure, some members will kick and scream that this doesn’t count as a “real” repeal. So too will some activists and interest groups. But they’ll get over it: $346 billion is a big tax cut.

 

What happens when the ACA is finally set to lapse? I honestly have no idea. The political scene will look very different in a couple of years.

 

It’s safe to say, however, that passing a reform bill would be even harder at that point.

 

Maybe I’m wrong about all of this. Maybe Republicans will pull together a plausible replace bill. Or maybe they really will just blow the whole damn thing up. My hunch, though, is that unwinding the ACA won’t be as easy as the political rhetoric suggests.

 

Harris Meyer, Modern Healthcare:

President-elect Donald Trump has promised to quickly repeal and replace the Affordable Care Act. Now he and the newly elected Republican Congress are like the dog that caught the car. What are they going to do with it?

 

One of their biggest problems will be how to fund the tax deductions or credits they have proposed to help people afford health insurance in their new system. That’s because repealing the ACA means erasing the hundreds of billions of dollars in taxes that pay for the law’s premium tax credits and Medicaid expansion. Last January, congressional Republicans passed a repeal bill that wiped out the subsidies, the Medicaid expansion, and most of the major taxes, including taxes on hospitals, health insurers, medical device makers, and high-income taxpayers. President Barack Obama vetoed it.

 

Abolishing the ACA would increase the federal budget deficit by as much as $350 billion through 2025, according to the Congressional Budget Office.

 

“The brutal reality that Republicans have been reluctant to discuss is if you repeal all of Obamacare, there is no money to insure all of the uninsured,” John Goodman, a veteran GOP health policy adviser who helped draft an ACA replacement bill sponsored by Rep. Pete Sessions (R-Texas) and Sen. Bill Cassidy (R-La.), said in a June interview.

 

Examining the challenges Republicans will face in financing health insurance subsidies illustrates the complexities and political tradeoffs involved in passing an ACA replacement bill. It suggests that Trump, who has promised to repeal and replace the ACA as one of his first acts in office, would have to invest a large amount of time and political capital on his healthcare overhaul, just as Obama did in his first year.

 

His various financing options are likely to anger powerful stakeholder groups. They include eliminating the Medicaid expansion and cutting Medicaid spending through defined federal contributions to the states; paring Medicare spending by tightening value-based payment programs to place healthcare providers at greater financial risk; and capping the tax exclusion for employer health plans, according to Christopher Condeluci, who worked as Senate Finance Committee Republican staffer during the drafting of the ACA.

 

Making the whole exercise politically harder is that one of the money-raising options—eliminating the ACA’s tax penalty for not buying insurance—would prompt fewer people to use premium subsidies but would drive up the uninsured rate. The CBO concluded (PDF) that the GOP repeal bill in January would leave 22 million more Americans uninsured. “That’s not great,” Condeluci said.

 

Most observers agree the Trump administration and congressional Republicans will have to offer at least some financial assistance to help people buy coverage in order to mitigate the number of Americans who would lose coverage with the repeal of the ACA’s generous premium tax credits.

 

Margot Sanger-Katz, The New York Times

New York is a great case study. Before Obamacare, it had the pre-existing conditions policy, but without subsidies or a mandate. When the Obamacare rules kicked in, premiums there went down by 50 percent.

This year, Obamacare premiums have risen substantially — an average of 22 percent around the country — leading many experts and politicians to question whether the law’s incentives were strong enough. Some, including Hillary Clinton, have argued that the government should sweeten the carrot, by making the subsidies more generous. Others have said that the stick should sting more by forcing the uninsured to pay a bigger penalty for sitting out of the market.

Republican politicians have tended to criticize both of the incentive provisions. The subsidies have been attacked as excessive government spending. The mandate has been criticized as an inappropriate use of government power. Both have been the subject of big Supreme Court cases challenging the law. Both would have been eliminated under a bill passed by Congress but vetoed by President Obama last year.

Taking away those unpopular pieces of the law and keeping the popular pre-existing conditions piece might seem like a political win. But it would result in a broken system.

When Mitt Romney was devising the Massachusetts health reform law that would become the model for Obamacare, he hoped to set up a marketplace for health plans with some financial assistance for low-income people to buy insurance. What he didn’t want was a mandate.

Then Jonathan Gruber, an M.I.T. economist who had calculated the results, showed him the numbers: His plan would cover only a third of the uninsured and cost two-thirds as much as an identical plan with a mandate. Mr. Romney embraced the mandate.

When Barack Obama ran for president in 2007, he, too, advocated a market-based health reform system. He, too, said he did not support a mandate. Then he became president, and economists brought him the numbers. By the time the Affordable Care Act passed, he had changed his mind.

We’ll see what happens when the economists bring the numbers to Mr. Trump. His transition website suggests that he might develop a different solution to the problem: a special, separate insurance market just for sick people.

But that plan is different from the more modest amendments to the Affordable Care Act he described to The Wall Street Journal. It won’t be easy to keep the basic architecture of Obamacare while plucking out its least popular pieces. (Another provision that Mr. Trump says he likes, the requirement that insurers cover young adults on their parents’ policies, would be easier to save.)