The Affordable Care Act, better known as Obamacare, has experienced hiccups of late.
An older, sicker, and more expensive pool of patients have led to losses for health insurers and pull backs from the ACA’s public exchanges. Increased costs — mostly in states that have not expanded Medicaid — and higher deductibles have put pressure on Americans’ wallets.
On the flip side, one of its successes has come from the fact that 20 million Americans who would did not have coverage before Obamacare now have it. Through the exchanges, Medicaid expansion or policies such as young people getting to stay on their parents’ insurance until they’re 26 years old, have driven down the uninsured rate in the US to an all-time low.
With the election of Donald Trump on Tuesday, however, the ACA appears to be in jeopardy. Trump has repeatedly promised to repeal and replace the ACA, and both Republican leaders in Congress — House Speaker Paul Ryan and Senate Majority Leader Mitch McConnell — said Wednesday that repealing the law was a top priority.
Trump released his heath plan on his transition website, greatagain.gov, on Thursday. While it was vague in its details, it appears to have one glaring flaw: It does not yet outline a solution for what to do with the over 20 million Americans with insurance from the law.
Based on the plan on Trump’s transitional website, there are some stabs at maintaining the coverage for these people.
“A Trump Administration will work with Congress to repeal the ACA and replace it with a solution that includes Health Savings Accounts (HSAs), and returns the historic role in regulating health insurance to the States,” read the Trump transition website.
HSAs are tax-advantaged accounts that can be used for medical expenses. These are typically used in conjunction with high-deductible insurance plans to help ease the burden of out-of-pocket costs. But HSAs alone are not a direct substitute for coverage, but typically used in conjunction. Additionally, most Obamacare plans are high-deductible plans already and a significant portion have HSAs.
Trump’s plan also seemingly contradicts itself in regards to regulation of health insurance and the ability to sell insurance over state lines.
“To maximise choice and create a dynamic market for health insurance, the Administration will work with Congress to enable people to purchase insurance across state lines,” read the Trump plan.
Currently, insurance is regulated on a state-by-state basis by insurance commissioners, who set their own rules. Trump’s plan to “do away with state lines” doesn’t necessarily increase coverage, experts say, and it would simply allow business to be domiciled in whatever state has the most favourable regulation or give more power to the federal government in regulating insurance.
Additionally, as noted by health-policy experts, state regulators are not the largest impediment to introducing plans in new areas. That would be setting up new hospital networks, instead.
Trump also proposed to reinstitute high-risk pools, which were plans that allowed people with preexisting conditions to get plans that were partially subsidized by the state government.
“The Administration also will work with both Congress and the States to re-establish high-risk pools — a proven approach to ensuring access to health insurance coverage for individuals who have significant medical expenses and who have not maintained continuous coverage,” said the Trump plan.
These plans, however, typically had premiums twice as high as normal individual health plans, which made them a serious deterrent for many of the people with ACA plans and preexisiting conditions. Additionally, only 226,000 people took part in these pools at their peak in 2011.
This also does not account for those that have received care from expanded Medicaid provisions. Trump has previously said that he would provide funding in a block for states to do as they please with Medicaid. The transition site reads that the administration plans to “enable states to experiment with innovative methods.”
Whether the 15.7 million people who have gained access to Medicaid through the ACA expansion will keep it is not clear from Trump’s plan.
Theoretically, by defunding the various parts of the law, these people could simply be out of luck. As Timothy Jost, a professor for health law at Washington and Lee University and an advocate of the ACA, told Business insider on Wednesday: “Some of them will die. That’s what happens when you lose health coverage.”
Interestingly enough, in the day after Trump’s election was the strongest day of enrollment for ACA exchange plans so far. Politico’s Dan Diamond speculated this could be because people want to access coverage before changes to the healthcare system.
That’s due to potentially good reason: The current Trump plan is vague, and there is a good chance contributions will come from congressional leaders such as Ryan. There does not appear to be a definite plan to cover the 20 million people who have plans due to Obamacare’s provisions.