Not quite one month after the election, President-elect Donald Trump is still sending mixed signals about his plans for the Affordable Care Act.
On one hand, in keeping with his campaign vow to repeal the health care law, his nominee to head health and human services, Georgia Rep. Tom Price, is a sworn opponent of the ACA, or Obamacare, who wants to eliminate coverage mandates and implement a more free-market system.
But his nominee for the Centers for Medicare and Medicaid Services, which manages more than $1 trillion in Medicaid and Medicare spending annually, including Obamacare’s expanded Medicaid dollars, is Seema Verma, who worked with Indiana and its governor, Mike Pence, the vice president-elect, to design that state’s customized Medicaid expansion plan.
These apparently conflicting moves are playing out against a backdrop of postelection public opinion that seems to show more Americans wanting to expand the law’s protections, not roll them back, and amid growing concern that if only some of its protections are rescinded, some citizens, and some states, could be affected more than others.
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As an Obamacare replacement takes shape, there are sure to be conflicts over specifics within the Republican Congress and the Trump administration, not to mention among the states, 31 of which have opted for ACA-fostered Medicaid expansion in some form. Twelve of those states are in Republican control.
The pre-election drumbeat “repeal and replace” might have slowed and softened a bit, with more nuanced talk from the president-elect emerging around transitioning away from Obamacare gradually and retaining its more popular components. But what does that look like?
Q: Will Obamacare be repealed?
Strictly speaking, it’s not likely. Outright repeal would take 60 votes in the Senate to beat a filibuster, and that would require Democratic votes. What doesn’t require filibuster-busting is budget reconciliation, under which key components of the ACA, such as Medicaid expansion, can basically be defunded. Reconciliation is the same method under which portions of the ACA were enacted in the first place so it would be hard for Democratic opponents to object.
Q: How quickly could Republicans act?
As for how it would be carried out, the most likely road map got its dress rehearsal last December and January, when Congressional Republicans once again pushed through an Obamacare repeal knowing its namesake would veto it.
“We have now demonstrated that, if we elect a Republican president, we can use this same path to repeal Obamacare without 60 votes in the Senate,” Ryan said at the time. “This is critical.”
Critical but not immediate. That dry run proposed a two-year phase-out before the actual shutdown began.
Q: What would that Republican plan look like?
Possible changes include cheaper plans that offer fewer benefits or coverages — ACA’s mandatory coverage, known as the essential health benefits, would be scrapped. We could see additional tax credits created to cover insurance premiums, allowing insurance to be sold across state lines, expanding the use of health savings accounts, and converting Medicaid payments to offer health care for low-income residents into state into block grants.
Richard Armstrong, Idaho’s state director of Health and Welfare, critically reviewed several of these proposals in a Nov. 16 meeting with the Statesman. On health saving accounts, for example, he noted that despite Idaho having used them for years, they are typically purchased by wealthier people with more disposable income and assets to protect. Interstate insurance selling, Armstrong said, was the “silliest argument I’ve ever heard,” given the cost differences between states.
“You cannot afford to sell an Idaho rate to somebody living in New York and think that your rates are going to stay put,” he said.
The most profound change could involve converting Medicaid payments to block grants. That gets its own section below.
Q: Any immediate changes for 2017? Should I apply for coverage?
Immediate changes are unlikely. It may take two years for a replacement to be enacted, and until one is, both Trump and congressional Republicans have offered assurances that current coverage will continue. So yes, you should apply for coverage if you need it. Open enrollment runs through Jan. 31.
Q: If not outright repeal, then what? What does the most likely change scenario entail?
The Better Way site offers some further detail. Opponents of Obamacare have consistently opposed mandated coverages for certain conditions that are among the essential health benefits. Idaho’s Armstrong sees potentially more plans on offer with varying premiums and varying coverage. Of course, that also means purchasers could be shut out if they are hit with medical problems excluded by their plan.
“So if they repealed ACA, then I would assume that we could start seeing benefits vary dramatically, and we’d start maybe skinnying down the benefits package to get a lower price,” he said.
Q: What about the things everyone says they like: coverage for children up to age 26, no exclusions for pre-existing conditions, free birth control?
The first two popular options came with costs, so if they are retained, what pays for them? The premise behind the individual mandate that requires all people to purchase insurance was that the large pool helps insurers recover the costs for covering the sickest people.
Trump has said he’d like to continue letting young adults stay on their parents’ insurance policies until age 26 — an idea that has been part of House Republicans’ health care plan. He and Republicans also have endorsed retaining the ACA’s prohibition against denying coverage to people with pre-existing conditions. The question is how both of those programs would be funded.
As for birth control coverage, the outlook is more tenuous. As Vox explains, HHS could simply redefine what it considers preventive health for women to exclude birth control.
Q: Will state health insurance exchanges such as YourHealthIdaho go away?
It’s not likely, not even in the long run, says Armstrong. The successful ones are too good to throw away, and Idaho’s is an unqualified success. Also bear in mind that, as this comprehensive Washington Post explainer spells out, at last count there are 214 million people in the U.S. with some kind of private health insurance. More than 80 percent are insured through work. The marketplaces provide insurance to only 11 million.
Q: What about Medicaid expansion? Idaho never implemented it. In hindsight, was that a good idea? What is the state doing for working poor who would have been covered by taking the additional Medicaid dollars?
People who opposed Medicaid expansion — those who oppose federal funding of such services — claim that Idaho will be proved prescient in delaying action on expansion, either by implementing or working out a waiver with the federal government for a modified version, as other states have. But that’s not entirely clear.
Brian Whitlock, president of the Idaho Hospital Association, which has worked to win over state lawmakers on the economic and health benefits of expansion, notes that conversations about the future of expansion now occurring nationally among health care professionals agency administrators and others focus on two main ideas: first, that the 31 states that have expanded Medicaid are not likely to let go of those federal dollars without a fight.
Second, if those dollars gets converted to a block grant allocation, the total provided is not likely to exceed the total amount currently distributed to just those 31 states.
So what happens to states like Idaho, that aren’t in the pool now? Will they be cut out of receiving any portion of the block grants? Will existing expansion states be OK with receiving a smaller share so that other states that held out get something?
“You can see where the pushback is going to come from the 31 states that have already stepped up to the plate, expanded Medicaid, and provided coverage to previously uninsured citizens in their states,” Whitlock said. “There isn’t going to be more money to do the same in those other 19 states.”
The uncertainty over expansion dollars and future allocations might lead to a scenario in the upcoming Idaho legislative session where, ironically, lawmakers pursue some sort of conditional expansion option with all kinds of sunsets and sideboards just to make sure to keep the state’s options open down the line. At the moment, all that a legislative working group has put forward is a strong recommendation that something be done in the coming session regardless of uncertainty at the federal level. Options include possibly expanding Medicaid, with some sort of sunset provision or escape clause if the federal funding ends. For the moment, lawmakers are taking the same wait-and-see approach as most everyone else.
Q: Aren’t Congress and the next president just doing what most Americans want by getting rid of Obamacare?
Popular opinion seems split. The nonprofit, nonpartisan Kaiser Family Foundation has tracked public opinion on the ACA since its inception in March 2010 and released its first post-election finding Thursday.
▪ One-fourth of Americans want the entire law repealed and 17 percent want it scaled back. But 19 percent want it kept as is, and 30 percent actually want it expanded.
▪ An overall uptick in the number of those who want ACA scaled back as opposed to repealed is driven by Republicans: 52 percent now favor repeal compared to 69 percent in October, and 24 percent now want it scaled back, compared to11 percent in October.
▪ Solid majorities of Republicans, Democrats and independents alike favor coverage for young adults on their parents’ plans, eliminating out-of-pocket costs for many preventive services (83 percent of the public, including 77 percent of Republicans), providing financial help to low- and moderate-income uninsured people to help them purchase coverage, preserving Medicaid expansion, and prohibiting exclusions pre-existing conditions. But only one third supports the law’s individual mandate.
“I really don’t get people who say they don’t want to be forced to buy health insurance,” said Pete Friedman, a retired city planner and planning consultant from Boise whose list of questions included many of those addressed here. “An uninsured or underinsured individual is one major illness or accident away from financial calamity. The rate payers actually cover those without insurance who are forced to use the emergency room for primary care.”
More health care questions
A few more Statesman readers’ health care questions not directly related to the future of Obamacare.
Why are insurance rates rising so much this year?
The New York Times had an excellent explainer on this in October, a couple of weeks before the election. There are plenty of caveats and exceptions, which obviously won’t do much to ease the pain for those who are facing big increases.
What kind of health care coverage do Idaho lawmakers get? Don’t they just serve part-time?
Legislators get the same health insurance options and subsidies as other state employees, although they are not paid as if they are full-time state employees. The Statesman covered this in a story last July. The numbers cited then are still valid, though the participation rate will change somewhat with the incoming Legislature. Additionally, a number of Idaho legislators are old enough to qualify for Medicare.
What about federal funding of community health centers that serve low-income clients? Don’t those facilities end up competing with private health care providers? Wouldn’t it be more fair and beneficial to public health if the money they receive went instead toward helping more people get insurance?
This is a question of apples to oranges. For one, community health centers such as Terry Reilly Health Services, also known as federally qualified health centers, are not-for-profit. Only a part of their funding is from federal grants. They are set up in medically underserved areas and are mandated to provide primary care services at a sliding scale, which can mean little or no payment to the provider. Private, for-profit health care providers don’t operate under the same requirements.
Because data collection is included in their mandate, there is good up-to-date information on who community health centers serve from the Idaho Primary Care Association. In 2015, Idaho’s 72 clinic sites in 47 communities served nearly 165,000 patients, or about one-tenth of the state’s population. A little more than one-third of those patients were uninsured, and about as many were on Medicaid or Medicare. The rest, a little less than one-third, had private insurance of some kind. Nearly half of all patients were below the federal poverty level, which is an income of $24,250 or less for a family of four.
The health centers “are an essential part of our state’s safety-net healthcare system” that provides care “regardless of a person’s insurance status or ability to pay,” said IPCA CEO Yvonne Ketchum-Ward. Federal support for them “improves Idaho communities and enables these clinics to provide life-saving primary care on a sliding fee basis to thousands of hard-working Idahoans.”