TrumpCare: The Uncertain Path to Repeal Part 2

In part 2 of this series, First Report Managed Care spoke with government insiders and managed care experts in order to tease out the complexities of the path to a repeal, replacement, or restructuring of the ACA. 

Repeal and Delay

According to Barney Spivack, MD, national medical director of Medicare case and condition management at OptumHealth, and a member of the First Report Managed Care Editorial Advisory board, “repeal and delay” appears to be the most likely option in the end.  

“Given all the stories about how the law has actually made a difference for many people, I don't see [immediate repeal] happening anytime soon,” he said. Repeal and delay, he noted, would also allow Republicans to “say they repealed the law,” without throwing the US health care system into tumult. 

It appears that they have most Americans on their side, according to a recent Gallup poll, more than half of respondents said they disapprove of the ACA. 

Most experts agree that the new law will be an amalgam of the “Empowering Patients First Act”—which Dr Price has introduced in Congress several times—and House Republicans’ “A Better Way” plan. 

The key elements of these two proposals include: 

• Medicaid expansion rollback;

• allowing states to impose work requirements for those Medicaid recipients who are able to work; 

• permitting states to charge premiums or limit benefits for certain beneficiaries; 

• replacing the insurance mandate and premium subsidies with a flat tax credit to those who need to purchase individual insurance;

• allowing insurance companies to deny coverage or charge more for preexisting conditions to those who have a gap in coverage;  and

• allowing insurance companies to sell their plans across state lines.

Mr Smith previously said some of the Medicaid changes might be challenging to implement, since requiring certain recipients to work and contribute to premiums might be perceived as racially biased by some. Now, he believes that Dr Price’s nomination—along with putting Seema Verma in charge of CMS—“may help these changes along.” 

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“Magic of the Marketplace” 

Mr Smith reiterated what he told us weeks before the election: of all the Republican proposals, expanding HSAs is, in his view, an easy-to-understand concept that could move along quickly under a Trump presidency. Expanding these accounts would give consumers more dollars to offset out-of-pocket costs. 

Such a plan, he said, “would not require a large outlay of dollars, and would be easy to administer. Plus, it appeals to the middle class. People like it and it and it makes sense.”

What we surely won’t see as Republicans prepare to run the show is the public option that President Obama originally wanted to include in the ACA, and Clinton probably would have considered. But her loss—coupled with the single payer Colorado Care measure being voted down on Election Day—all but assures that there will be no talk of universal health care over the next 4 years.

“I believe the election results, and the strong ‘no’ vote on Colorado Care indicate that the country is not ready to migrate to a single-payer system,” Mr Leavitt said. “While there is a widely-held aspiration for all Americans to have access to an affordable insurance policy, there is still a desire for market competition and consumer choices.”  

Dr Spivack concurred. “There may be more support than there was a few years ago, but this now has no chance in a Republican-controlled government that believes in the magic of the marketplace for the delivery of health care.”

Mr Smith generally agreed, but added that “we may [eventually] migrate to a modified single-payer system, with government being the largest payer. Private exchanges will take the place of employer-based insurance. In this scenario, risk management providers will move towards a rather homogenous benefit designs.” 

Lest anyone think such a scenario is far-fetched, Mr Smith argued that this system is already in motion, explaining that he was recently placed into a private exchange through, his spouse’s employer.