While every new year brings change, with Donald Trump elected to become the next president and the U.S. House and Senate both having Republican majorities, managed healthcare executives will see more changes than usual in 2017—beginning with repealing and replacing most of the provisions in the Affordable Care Act (ACA). Experts in the industry state their cases for what they expect will occur over the coming months regarding the ACA, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), CMS, Medicare, Medicaid, and more.
ACA changes
Trump made repealing and replacing the ACA a core position of his presidential campaign. “Although Trump will help to drive the approach and agenda for such an effort, congressional Republicans will bear most of the burden for fulfilling this promise,” says S. Lawrence Kocot, MPA, JD, LLM, national leader, Center for Healthcare Regulatory Insight, KPMG, LLP. “Attempting to repeal the law as a whole through regular order is highly unlikely given the probability of a likely Democratic filibuster. The more likely path would be to repeal portions of the law through a reconciliation bill (similar to H.R. 3762, an approach that passed the House and Senate before being vetoed by President Obama in 2015). This reconciliation would likely target some major provisions such as the individual and employer mandate, insurance subsidies, and Medicaid expansion funding, while preserving some that enjoy bipartisan consensus, such as guaranteed issue and insuring children up to age 26 on their parents’ policies—which Trump said he may support after he was elected.” Congress would then likely craft a replacement bill that could contain new approaches to cover millions of Americans that might lose coverage through a repeal effort.
But the timing of repeal and replacement is uncertain; the repeal process could occur as early as Trump’s inauguration day of January 20, but the crafting of a replacement could take significantly longer as a growing number of congressional Republicans seem to agree that bipartisan support may be necessary for this to be sustainable, Kocot continues.
Finally, the new administration could starve health insurance exchange funding and alter other regulatory provisions of the ACA through regulatory and sub-regulatory processes, or through non-enforcement, Kocot notes.
Joel White, president of the Council for Affordable Health Coverage, also expects Trump to make repealing and replacing the ACA a top priority. “The market faces significant challenges, including rising costs and premiums, less competition, and weak enrollment,” he says. “Both Republicans and Democrats want to improve the market, but differ significantly on how to do so.
“What cannot be repealed or blocked through regulations, Congress will repeal and replace,” White says, adding that he believes the replacement will focus on affordability, then access, and then coverage and will include some of the provisions already in law.
Sally C. Pipes, president and CEO, Pacific Research Institute, points out that Speaker of the U.S. House of Representatives Paul Ryan—along with House Republications—has already put forward a replacement plan, “A Better Way,” which would repeal many of Obamacare’s mandates and regulations. However, it is not in legislative form yet nor are the costs worked out.
The GOP plan also provides $25 billion in funding over 10 years to state-level “high-risk” pools. “These pools would provide subsidized coverage for individuals with extremely expensive chronic conditions to manage,” Pipes says. “That leaves the standard insurance pool with patients who have common, actuarially predictable health risks. Insurers would be able to predict with much greater accuracy how much it would cost to pay for these individuals’ care—and could therefore offer lower, more stable premiums.”