With Donald Trump headed to the White House and his party firmly in control of Congress, Republicans will finally have a chance to prove what they’ve been saying all along: that they can produce a better version of healthcare reform than the Affordable Care Act.
It’s clear that the ACA is as imperiled as it has ever been. Trump has fervently vowed to repeal it–and with Republican control of both chambers of Congress, he may well get his wish. After all, the law’s most visible component, the exchanges, are on shaky ground as it is, with premiums rising and some health insurers retreating from the marketplaces.
Plus, President Barack Obama’s last attempt at convincing Republicans to work on fixing the ACA–not repealing it–fell on deaf ears even before the party’s resounding victory Tuesday.
What gets lost in all the talk about the ACA’s uncertain future, though, is the fact that while some insurers have struggled to make a profit in the individual marketplaces, there are other aspects of the law to which they have become quite attached.
Take Medicaid expansion, an idea championed by Democrats (and even once embraced by Vice President-Elect Mike Pence) that has been a boon to insurance companies in the form of lucrative managed care contracts. Some companies that specialize in slimmed-down Medicaid plans have also thrived on the exchanges where others have floundered.
Then there’s the ACA’s provisions that encourage the transition to value-based payments, which insurers have embraced and largely retooled their business models to reflect. Accountable care organizations, for example, have sprung up like wildfire, producing promising results for some companies.
A wholesale repeal of the ACA would also erase the law’s historic gains in reducing the uninsured rate. Though many of the newly insured have turned out to be costlier to cover than expected, such a move would still rob insurers of millions of new customers.
The question, then, becomes what will replace the law–and that’s where it gets interesting.
Trump has a plan, but it is short on details. Perhaps most visibly, he has advocated for selling insurance across state lines–a timeworn GOP talking point that many experts agree is not feasible. He would also repeal Medicaid expansion and convert Medicaid federal matching funds into a block grant, the latter of which would drastically cut Medicaid funding and coverage.
One analysis from The Commonwealth Fund says that his plan could add nearly 20 million peopleto the ranks of the uninsured, and even more if his Medicaid proposals come to fruition.
HENRY KOTULA 