Congressional Republicans have vowed to replace the Affordable Care Act (ACA). President-elect Trump’s transition team and GOP leaders are devising the details of a plan to vote for repeal in early 2017. They are taking a close look at the budget to pass a reconciliation bill that will take priority in the first 100 days Trump is in office to deliver on campaign promises.
Trump believes that replacement and repeal need to be done simultaneously, but that would require finding the answers to some complex questions. Congress has strained the system to hit synchronized legislative deadlines in the past and created political pressure to handle important bipartisan deals, but in this situation, millions of people stand to lose health insurance protection if it fails.
The public was forced to accept the massive ACA law in one huge bill, but Republicans don’t want to approach their legislation this way. Senate Republicans are talking about moving the replacement legislation in stages by:
- Undertaking the sale of insurance plans over state lines,
- Finding the best way to deal with pre-existing conditions, and
- Providing new insurance plans for small businesses
There needs to be a more concerted effort to find the best solution for the country, which takes time, especially if Trump wants to preserve portions of the law to protect those with pre-existing conditions and allow young people access to health care on their parents’ health insurance until age 26. Costs will be much higher to make this happen. He also needs a solution for the millions of people currently relying on Medicaid expansion that could lose coverage.
Most Republicans want to deal with the replacement later to buy extra time so that they can convince Senate Democrats to pass the legislation. If Republicans pick up some of those seats instead, they could have a larger Senate presence to pass replacement legislation in 2019 or 2020 as well.
With the health insurance of 20 million Americans at stake, the alternative plans must be convincingly viable to replace Obamacare’s most popular provisions. The Senate needs to fully understand how new provisions will benefit the nation’s health care needs as well as the products, services and financial goals of the health insurance industry. Repealing without outlining the replacement structure first could cause disaster. For that reason, when the GOP tried to pass a repeal bill in 2015, it would have included a two-year delay. This plan could be the best place to start building a new design, but it will extend repeal and replacement out to 2019 or 2020 while Republicans are waiting to form a consensus.
Repealing Too Soon
Insurance companies and the healthcare industry will need to re-engineer all their previous changes for Trumpcare the same way they did when first implementing Obamacare. Insurance providers must feel financially secure about the future of the new program. If not, they could leave the marketplace prematurely and leave 10.4 million Obamacare marketplace enrollees without coverage to avoid risk. Trying to get a repeal vote before devising the replacement puts insurers in a difficult position as they are just now putting health plans together for 2018 without knowing what their plan offerings should contain.
The marketplaces depend on private insurers selling insurance coverage, and they’re already struggling. People who have been buying coverage are sicker and older than insurers originally expected. Young, healthy individuals opted to pay the penalty fine that was less expensive than annual premiums, and funds fell short to support high-risk enrollees. Retaining insurers in rural areas with smaller populations also became a concern as 960 counties were left with only one ACA insurer.
From a practical standpoint, insurers can’t wait until 2020 to know if they are going to continue to deal with the same risk pool without government assistance for potential losses through subsidies. With no decisions on plans, coverage or funds, it’s difficult to understand Trump’s conflicting statements.
One Step at a Time
Trump’s administration can repeal funding for the Affordable Care Act in early 2017, delay the effective date of that repeal until 2019 or 2020, hope to bridge the bipartisan divide by the next elections in 2018, and develop the replacement plans that can get the necessary votes during a two to three-year window. But there’s a long way to go – and a lot of work to do – before the country adjusts to yet another attempt at health care reform. With hard work and patience, a Republican repeal and replacement bill may turn out to be good public policy, but there are plenty of what-ifs still hanging in the balance.