On November 8, 2016, the fate of the Affordable Care Act (ACA) was all but sealed.
In a sweep of the legislative branch, Republicans maintained majorities in the House and Senate, and Donald Trump became the 45th president, running on the popular Republican refrain to “repeal and replace Obamacare.”
“Now, the real onus is going to be on them if they do move to repeal it in its entirety,” says Joshua Lenchus, DO, RPh, FACP, SFHM, a hospitalist at the University of Miami/Jackson Memorial Hospital in Florida and a member of SHM’s Public Policy Committee. “It’s going to be a real burden to replace it with something meaningful and not something that’s recycled from six or eight years ago when the conversation first started.”
In the days following the election, President-elect Trump appeared to be backing off his campaign promises to repeal President Barack Obama’s landmark health reform law, acknowledging that at least some of its provisions should remain intact, including maintaining the ban on insurance companies denying coverage based on preexisting conditions and allowing dependent children to remain on their parents’ health insurance until age 26.
These ideas are also part of House Majority Leader Paul Ryan’s healthcare plan, called A Better Way. However, at least on the campaign trail, Trump and GOP leaders like Rep. Ryan did not see eye-to-eye on all aspects of health reform, including how to deal with Medicare and on issues of pharmaceutical regulation, leaving uncertainty over which platforms will be adopted.
What Comes Next?
“There is a lot of rhetoric out there and a lot of promises to replace the Affordable Care Act, which clearly is an important objective for Republicans, but as sort of a consolation, as [health economist] Stuart Altman used to say before the Affordable Care Act was passed, ‘Everybody’s number-one choice is universal health reform the way they want it, and the second is the status quo,’” says Sherry Glied, MA, PhD, health policy expert and dean of New York University’s Robert F. Wagner Graduate School of Public Service.
But the status quo is no longer an option. Passage of the ACA was driven by high healthcare costs in the U.S. and, in part, around access to coverage. Healthcare spending slowed after passage of the ACA, and while it cannot be fully attributed to the law, cost remains an issue.
The Congressional Budget Office (CBO) estimates that repeal of the ACA would increase the federal deficit by $137 billion to $353 billion between 2016 and 2025, growing even more after 2025.1 And without a mechanism to cover the 20 million people who have gained coverage through Medicaid expansion and private insurance coverage on state exchanges, scores of people could rejoin the ranks of the uninsured.
A Series of Small Cuts
“Whatever system replaces it, don’t expect in Trump’s first week in office Congress will hand him a bill to repeal and replace Obamacare. They’ve tried to do that a number of times in the past, and what they’ve come up with has been a little lackluster. And that’s being generous,” says Dr. Lenchus, who overall supports President-elect Trump’s economic plans and is optimistic about what they could mean for health reform.
Most likely, the ACA will not be repealed in “one fell swoop,” says Glied, who also served under President Obama in the Department of Health and Human Services from 2010 to 2012 and was a senior economist for health care and labor market policy under Presidents George H.W. Bush and Bill Clinton. Rather, lawmakers are likely faced with having to “demolish it through a series of small cuts.”