You’ve seen the headlines and you’ve heard the slogans: Obamacare is on the chopping block and President-elect Donald Trump is going to replace it with “something terrific.”
But what are the new president and Congress really going to do? How much of the current law will really go away? And what could “Trumpcare” look like?
In case it’s been a while since you read about the Affordable Care Act and the GOP replacement plans, here’s a refresher on the biggest Obamacare issues.
http://www.sacbee.com/news/politics-government/capitol-alert/article116320043.html
They backed Obamacare, and they’re not letting it go without a fight.
The federal healthcare overhaul could be one of the first casualties of President-Elect Donald Trump, who has joined the Republicans controlling Congress in vowing to dismantle the law. Since winning the presidency Trump has softened his stance somewhat, speaking favorably about popular provisions that prohibit insurers from turning away people with pre-existing conditions and allow people to stay on their parents’ plans until they turn 26.
Still, Trump’s election has California healthcare advocates on high alert, not to mention the state’s new U.S. senator. California could forfeit billions of federal dollars that support Medi-Cal, the insurance program for poor Californians, and subsidize private insurance purchases. They’re worried about the fate of Medicare, a program that Speaker Paul Ryan, R-Wisconsin, said has “serious problems because of Obamacare” and is “going broke.”
BY THE NUMBERS: 13.6 million is the number of Californians enrolled in Medi-Cal as of June 2016, the most recent data available, a net increase of about 800,000 from a year earlier and about double Medi-Cal enrollment a decade ago. The total includes almost 3.4 million people who became eligible for Medi-Cal under the state’s optional Obamacare expansion. The Legislative Analyst’s Office last week reported that Medi-Cal caseload should grow by about 100,000 annually through mid-2021 among families, children and people covered by ACA expansion. Enrollment among senior citizens and people with disabilities will grow by an estimated 50,000.
The vast majority of healthcare organizations and professional groups support Medicaid expansion, the Obamacare initiative to widen eligibility for Medicaid to individuals earning up to 138% of the federal poverty level. To them, the benefits of expansion, such as less bad debt and uncollectible bills, better patient access to services, and an overall healthier patient population, outweigh the additional costs for states to bear after the full federal reimbursement period expires. But a subsequent Supreme Court ruling left the decision to implement Medicaid expansion up to the individual states. To date, 31 states and DC have implemented the expansion, the majority of them launching new Medicaid eligibility guidelines starting in 2014. Why hasn’t it been approved in the other 19? Often it is attributed to the state’s dominant political party, but that alone isn’t a reliable indicator, given that red states like Ohio and North Dakota expanded the program, while others like Maine and Virginia did not. Judging from a review of Definitive Healthcare data, there is another possibility: hospitals in non-expansion states were in a better financial position and so there was less political pressure to widen Medicaid eligibility.
At a national level, the expansion of Medicaid continues to yield benefits. Its coverage was increased, and its quality raised. Some states that have expanded Medicaid are even expecting net savings for the next few years. In states where Medicaid was expanded, hospitals had fewer uninsured visits.
Focusing on only the positives can be as misleading as focusing on only the negatives. Policy decisions, including those involving health, need to be considered in terms of trade-offs. It is true that providing Medicaid can cost the federal government, and even states, a lot of money, which can’t then be spent on other worthy pursuits. It is true that Medicaid reimburses physicians and hospitals less generously, and that it often leaves beneficiaries with fewer choices than private insurance might.
But when we look at the balance sheet for Medicaid — health benefits, financial security, societal improvements through education — it’s not hard to argue that money allocated to Medicaid is well spent.
The last six and a half years have been uncharted territory in our nation’s century-long debate over health reform. For the first time the fight was about how to implement an attempt at near-universal coverage rather over what this plan should look like and what could win enough support in Congress. The Affordable Care Act (ACA) has survived major political, legislative, and legal tests, including dozens of repeal votes, two Supreme Court decisions, the 2012 presidential election, and state-level resistance.
I was outside the Supreme Court on June 25, 2015 when the King v. Burwell decision was released. I was there the moment activists switched their signs from saying “Don’t you dare take my care” to “The ACA is here to stay.” I wrote that we could finally say with some certainty that they were right, the law is here to stay. They were wrong. I was wrong.
Donald Trump’s victory throws the future of health reform into complete chaos. He will take office in January 2017 with Republican majorities in the House and Senate. President Trump, Speaker Ryan, and Senate Majority Leader McConnell have all made repeated promises to get rid of Obamacare. They will face enormous pressure to follow through with their threats of repeal. Approximately 21 million people are projected to lose insurance if they follow through with their initial proposals.
The first step to figuring out where to go from here is understanding what decisions are on the horizon. Here are my first 20 questions about health reform under the Trump administration , in no particular order:
http://www.commonwealthfund.org/publications/issue-briefs/2016/nov/medicaid-block-grants
Issue: President-elect Trump and some in Congress have called for establishing absolute limits on the federal government’s spending on Medicaid, not only for the population covered through the Affordable Care Act’s eligibility expansion but for the program overall. Such a change would effectively reverse a 50-year trend of expanding Medicaid in order to protect the most vulnerable Americans.
Goal: To explore the two most common proposals for reengineering federal funding of Medicaid: block grants that set limits on total annual spending regardless of enrollment, and caps that limit average spending per enrollee.
Methods: Review of existing policy proposals and other documents.
Key findings and conclusions: Current proposals for dramatically reducing federal spending on Medicaid would achieve this goal by creating fixed-funding formulas divorced from the actual costs of providing care. As such, they would create funding gaps for states to either absorb or, more likely, offset through new limits placed on their programs. As a result, block-granting Medicaid or instituting “per capita caps” would most likely reduce the number of Americans eligible for Medicaid and narrow coverage for remaining enrollees. The latter approach would, however, allow for population growth, though its desirability to the new president and Congress is unclear. The full extent of funding and benefit reductions is as yet unknown.
In a stunning upset, Donald Trump took the stage early yesterday morning to claim victory as the next president of the United States while Republicans celebrated retaining control of both the House and the Senate.
While the outcome of the election has long been expected to have a far-reaching impact across a number of policy areas, the Republican sweep of Congress and White House could result in profound changes in health policy after a hard-fought election on both sides of the aisle.
Although the exact implications of the race will become more apparent in the coming days and weeks, we expect Republicans to emphasize the election results as a mandate for change and use the opportunity to pursue significant new initiatives.
So what can providers expect from a Trump administration and a GOP Congress? Let’s take a look at what’s potentially in store for Medicare, Medicaid, and the private insurance market—and what those changes mean for provider strategy—by looking at the most common questions I’ve already received following the election.
Despite its seemingly endless political and financial travails, Obamacare has taken a big bite out of the number of uninsured Americans since it was enacted in 2010. An estimated 20 million more people are now covered by private health insurance obtained through subsidized government exchanges or expanded Medicaid for the poor.
But as the curtain begins to ring down on President Obama’s administration, roughly 20 million to 24 million people still lack health insurance, a huge piece of unfinished business that will be left to the next president and a new Congress to address. And that raises two interesting questions: precisely who are the uninsured today and why haven’t they been able to obtain coverage?
A national survey by the Commonwealth Fund conducted last February through April finds “notable shifts” in the demographic composition of the uninsured since the Affordable Care Act first took effect in 2014.
A quick snapshot of the detailed findings tells the stories of millions of people either purposefully rejecting health care insurance, not qualifying for a federal program, or being unaware of their options to acquire coverage.
Three years into the Affordable Care Act, there remain places where many people still lack health insurance. But their share keeps shrinking.
The share of people without health insurance keeps falling.
Since 2013, when the major provisions of Obamacare went into effect, the uninsured rate has fallen in every state. And some states that you might not expect have led the way.
The news about the Affordable Care Act has been grim lately: The price of health plans in new marketplaces is up, and choice is declining in many places. But amid the difficulties, new data highlight the law’s effectiveness in getting coverage for millions of Americans.
Over all, the gains are substantial: a seven-percentage-point drop in the uninsured rate for adults. But there remain troublesome regional patterns. Many people in the South and the Southwest still don’t have a reliable way to pay for health care, according to the new, detailed numbers from a pair of groups closely tracking enrollment efforts. Those patterns aren’t an accident. As our maps show, many of the places with high uninsured rates had poor coverage before the Affordable Care Act passed. They tend to be states with widespread poverty and limited social safety nets. Look at Mississippi and Texas, for example.
But many of the places that have reduced their uninsured rates the most had similar characteristics in 2013. Look at Kentucky and Arkansas. Over the years, you can see them diverge sharply from their neighbors.
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 