Over the course of his presidential campaign, Donald Trump promised time and again to “repeal and replace” the Affordable Care Act. Repealing and replacing the ACA has been a cornerstone for conservatives over the last six years. Republican members of Congress have attempted many times to undo the law on technicalities, weaken its effectiveness and limit its scope. Trump’s campaign website asserted that Obamacare needed to be demolished altogether. None of these efforts have proved successful, but with a Republican president and Congress, millions of Americans – especially those 20 million who have health insurance thanks to Obamacare – are now wondering whether Trump can follow through on his promise to repeal and replace the ACA. More important is not whether he can but whether he will.
The Law as It Stands
Before we talk about Trump’s vision for the American healthcare system, we should go over the changes that have been made to the system as a whole since the Affordable Care Act was signed into law in 2010. According to the Department of Health and Human Services (HHS), about 20 million people have gained health insurance thanks to the ACA. Just over half of these newly insured individuals have gotten plans from the federal or state marketplaces. Under the law, every eligible American has to have minimum essential coverage. This requirement is known as the “individual mandate,” a concept that President-elect Trump wants to eliminate.
The individual mandate has been wildly unpopular among conservatives and other opponents of the law, but even supporters of Obamacare have questioned the need to force individuals to get covered. In a country built on the idea of personal freedom, imposing fines on citizens for not having insurance seems counterintuitive. However, the Affordable Care Act sought to make health insurance not only accessible but affordable. In order for more people to be able to buy coverage, everyone needed to participate in the system. A larger risk pool, especially one filled with healthy individuals who don’t need as much care, drives down costs.
All current healthcare plans must cover 10 essential benefits, and preventive care is covered with no copays. That means that your annual wellness visit, during which your doctor conducts a full physical and makes sure that there aren’t any underlying problems that need to be addressed, won’t cost you anything apart from your monthly premium. Hospitalization, lab work, pediatric vision tests, mental health counseling and other medical services are among the 10 essential benefits guaranteed by the ACA. You may still pay copays or coinsurance for these services, but your costs will be less because they’re covered by your plan.
Not only did major medical plans become more comprehensive under the ACA, but insurers have also been brought to task. Insurance companies now have to spend at least 85 percent of premium revenue on services for beneficiaries, leaving just 15 percent to administrative costs. They also have to cover people with pre-existing conditions – like diabetes, high blood pressure, autoimmune disorders and pregnancy – without discrimination. Men and women pay the same rates for the same services. And if you have a health insurance policy, you can’t be dropped arbitrarily or just because you get sick.
The ACA has improved the lives of millions of American consumers, but it’s not a perfect healthcare law. Critics have been trying to dismantle it since it was a bill in Congress. Even proponents of the law recognize its limitations. President-elect Trump spent much of his campaign reiterating the need for a complete healthcare overhaul.
But what this overhaul looks like – and how it would be accomplished – remains unclear. In his 7-point plan for replacing the ACA, Trump has not been specific about how he intends to undo Obamacare. Congressional Republicans developed their own plan apart from Trump during his campaign, but now it appears as though they may be working with the soon-to-be president to accomplish similar objectives. But even if Trump and Congress get on the same page, there’s still the question of whether Obamacare will actually be repealed.
Trumpcare vs. A Better Way
Under Trump’s “Health Care Plan to Make America Great Again,” which has been outlined on his campaign website for several months, the goal is clear: repeal and replace what Trump considers to be a malfunctioning healthcare law. The original plan covered seven points:
- Completely repeal the current law.
- Allow the sale of health insurance across state lines.
- Let individuals deduct premiums from their taxes.
- Make Health Savings Accounts better and more useful to people.
- Require healthcare providers to be transparent about pricing.
- Use block-grant funding with state Medicaid programs.
- Allow people to buy prescriptions overseas.
Since Donald Trump won the presidential election on Nov. 8, a new site has been launched to help transition the President-elect into assuming the official title in January. Trump’s transition site, GreatAgain.gov, features policy updates and other information related to the transition period. His stance on healthcare has apparently changed somewhat. His new approach to healthcare reform “recognizes that the problems with the U.S. healthcare system did not begin with – and will not end with the repeal of – the ACA.” President-elect Trump now appears to be more willing to work with Congress and the states to further reform the healthcare system. New goals include:
- Protecting “individual conscience” regarding healthcare
- Ensuring the safety and wellbeing of all human life “from conception to natural death,” which includes people with disabilities and unborn babies
- Advancing research in healthcare
- Reforming the Food and Drug Administration to encourage innovation in the development of medical products
- “Modernizing” Medicare so that the program can serve the increasing number of Baby Boomer retirees and future generations
- Maximizing flexibility when it comes to state-administered Medicaid programs while encouraging innovation in healthcare delivery methods to low-income citizens
The transition site maintains much of the language of Trump’s original campaign site. Despite acknowledging that problems with the American healthcare system existed before Obamacare, Trump still intends to repeal and replace the current law. Verbatim from his new transition website:
The Administration’s goal will be to create a patient-centered healthcare system that promotes choice, quality and affordability with health insurance and healthcare, and take any needed action to alleviate the burdens imposed on American families and businesses by the law.
How the Trump administration intends to accomplish these goals remains unclear. To muddy the waters further, not every Republican agrees on how to reform health care, which is why Republicans in Congress have yet to introduce a successful bill to replace the ACA since the law was passed in 2010. Earlier this year, House Speaker Paul Ryan introduced his health care plan under a set of national reforms he calls A Better Way. In it, Ryan outlines four principles that are guiding the Republican health care plan:
- More choices with lower costs
- Real protections and peace of mind
- Cutting-edge cures and treatments
- A stronger Medicare system
In essence, Ryan wants to eliminate the individual mandate and allow consumers to choose a health care policy that fits their needs. Under this plan, people with pre-existing conditions and those who fall under discriminatory categories – such as age, income and health status – would still be able to buy health insurance. The plan also seeks to eliminate “bureaucracy” so that innovation can be made in terms of medical care, and the Medicare program would be strengthened for current beneficiaries as well as future participants.
A snapshot of how these goals will be accomplished is available on the plan’s website. Ryan makes it clear that A Better Way is the Republican answer to health care reform after so many years of disjointed efforts. Trump’s plan, while incomplete, shares many of the same ideas. Both Trump and his party want a patient-centered approach to health care reform, and both want to preserve Medicare. Both have also recognized the importance of keeping certain provisions of the Affordable Care Act intact, such as ensuring that people with pre-existing conditions get covered.
Where A Better Way differs from Trumpcare is its hardline stances on specific issues, like reproductive health. Trump adopts a pro-life stance in vague terms on his transition website, vowing to “protect innocent human life from conception to natural death.” Ryan takes this concept a step further, promising to prevent “federal taxpayer dollars from being used for abortion or abortion services and [ensuring that] the Hyde Amendment is actually applied.”
It’s been assumed since Trump won the election that he will be able to simply push through ay agenda he sees fit because he has a Republican Congress at his disposal. But a party-dominant government doesn’t necessarily guarantee success for that party, especially when the president and members of Congress can’t agree on certain points. Trump’s approach to health care may be more liberal than conservatives hope or want. Trump himself may prove to be more moderate – at least in his willingness to work with members of the Democratic party – than the media has so far given him credit for. With a history of voting Democrat, Trump is relatively new to the right side of the political spectrum. These facts together may prevent Trump from repealing and replacing the health care law in full.
Pros and Cons of Repeal
Repealing the Affordable Care Act could strip health care coverage from about 22 million people, the same people who currently have insurance thanks to Obamacare. Income-based subsidies and the expansion of Medicaid have made it possible for millions of people to take care of their health over the last six years. Healthy populations need less medical care in the long run, so it should be the goal of any government to ensure that its citizens lead healthy lives. There are substantial cons to dismantling the ACA, including:
- Uncertainty about coverage for millions of Americans, particularly those with limited resources, pre-existing conditions and other medical needs
- Lack of access to funding that helps lower-income citizens gain coverage
- The elimination of the individual mandate, which compels young and healthy people to sign up for coverage and bring down costs nationwide
- Eliminating the employer mandate, thus preventing millions of workers from getting covered through their jobs
These are serious consequences that the GOP and President-elect Trump will need to address before they undo the work that’s been done under Obamacare. The fact that 22 million people – and some estimates range from 16 to 25 million if Trump’s plan is adopted in full – could lose health insurance under Trumpcare will give Republicans pause. It’s a politically disastrous move to oust millions of American families, children included, from health insurance just to prove a point. Despite these significant challenges, there are some pros to repealing the law and replacing it with certain aspects of Trump’s plan. These include:
- More control over personal spending through Health Savings Accounts
- The ability to purchase prescription drugs overseas, which could lower costs
- Eliminating the individual mandate, which may relieve a burden on some
- The modernization and strengthening of Medicare
You’ll notice that eliminating the individual mandate could be considered a pro or con. Like many of Trump’s proposals and health care reform in general, some features could have a positive or negative impact on coverage depending on how they play out over time. For instance, stripping the health care law of its individual mandate would most likely result in fewer people signing up for health insurance, especially the highly sought-after demographic of young and healthy individuals.
However, if the Republican replacement plan offers attractive enough health insurance options to people on an individual basis – customizable coverage, low premiums and higher-deductible plans – then more people may sign up even without an individual mandate. And most Americans reject the idea of a health insurance requirement in the first place, which makes eliminating the mandate a politically advantageous move.
Repealing, Replacing, and What Comes Next
In recent interviews, Trump has said that he appreciates at least two specific features of the Affordable Care Act, and House Speaker Paul Ryan agrees: allowing young adults up to age 26 to stay on their parents’ health plan and requiring insurers to cover people with pre-existing conditions. Ryan reiterated support of these features in a 60 Minutes interview on December 4. These have been especially popular provisions across party lines. But how Trump and the GOP intend to keep these provisions without the benefit of the individual mandate is again unclear. In a seemingly contradictory set of tasks, Republicans want to:
- Protect young people
- Protect people with pre-existing conditions
- Grant “affordable” access to health insurance for “everyone” in the U.S.
- Offer “better coverage at a better price”
- Ensure that “no one” is “worse off” than they are today
But how they can accomplish these goals while axing most of the existing health care law is perplexing, to say the least, and probably impossible according to political analysts. To confound matters further, Republicans have recently adopted a “repeal and delay” approach to health care reform. Essentially, the Affordable Care Act will be repealed once Trump takes office in January, but Republicans will delay implementation of the repeal until they can create an appropriate replacement plan – a process that may take up to three additional years after repeal. There are several reasons for their approach:
- Repealing the ACA based on budget reconciliation procedure now will let Republicans dismantle the law without Democratic approval.
- Without a consensus on a replacement plan, Republicans are giving themselves a deadline to get on the same page and introduce legislation that upholds conservative values while still providing coverage for Americans nationwide.
- The “delayed” time frame and a set deadline may also encourage Democrats in Congress to get on board with a GOP plan down the line, especially if they might otherwise take the blame for not cooperating when it comes time to vote on a new health care plan.
Not all Republicans agree with “repeal and delay.” It’s a risky strategy, both in terms of what it means politically and how it might impact the health insurance market. Even Trump appears to prefer an immediate “repeal and replace” approach over the delay tactic.
But the fact remains that Republicans have yet to agree on an ACA replacement plan, which makes the repeal-and-delay strategy their only option for following through on a promise to repeal Obamacare immediately. President-elect Trump will be sworn into office in January. As we gear up for a Republican presidency and party-controlled government, the question of whether Trump will replace the Affordable Care Act will play an integral role during his first days in office.