Affordable Care Act Repeal Will Not Be Quick or Easy, Experts Say

Marcia Frellick

December 14, 2016

President-elect Donald Trump and Republicans in Congress are looking for a way to quickly repeal the Affordable Care Act (ACA) without millions of Americans losing health insurance. However, quick and easy is unlikely, experts say.

The emerging strategy is "repeal, delay, and replace," and it comes with a host of complications, writes Robert Doherty, senior vice president of governmental affairs and public policy at the American College of Physicians, in an opinion piece published online December 13 in Annals of Internal Medicine.

If Congress is able to pass a repeal-and-delay law, Doherty says, millions will lose coverage because insurers, unsure about a replacement plan, will likely flee the ACA insurance markets by the end of 2017.

The strategy may have direct consequences for many groups, according to Doherty. "The people who will be most affected by repeal include working-class people, women who are concerned about loss of coverage for contraception, and entrepreneurs with medical conditions who fear they will have to give up their start-ups for jobs that offer coverage — not to mention the many more people with pre-existing conditions who may again find themselves turned away by insurers."

Budget Reconciliation Strategy

The GOP likely will use budget reconciliation to repeal parts of the ACA early in the Trump administration. Under that approach, senators can't filibuster a bill, so it could pass with a simple majority, easily done with Republican votes.

However, reconciliation would only work for those parts of the ACA that reduce the federal deficit. Congress can't use it to eliminate provisions that are "merely incidental" (determined by the Senate parliamentarian) to reducing the deficit.

The GOP tried a test bill early in 2016, which, as expected, President Obama vetoed. Under that bill, the parts that would have been "merely incidental" would have included required minimum benefits, bans on not covering people with pre-existing conditions, and a ban on limiting annual and lifetime coverage.

Republicans will likely try a similar bill in 2017, Doherty writes.

"Some conservatives want to expand reconciliation to include repeal of the entire law, arguing that the whole law affects the deficit," Doherty says.

Overhaul Won't Come Quickly

Tom Miller, resident fellow of the American Enterprise Institute, a conservative think tank based in Washington, DC, told Medscape Medical News that changes will likely come at a much slower pace and be less drastic than Doherty and others have projected.

He said about repealing parts of the ACA: "I would agree with him that it's difficult. I would disagree that what makes the healthcare industry comfortable is most important."

Miller says changes will come somewhere between the extreme rhetoric of the opposing sides that now say either the whole Act needs to be blown up or nothing is touchable because changing one thing changes everything else.

"Things are going to tone down a bit, when you need some more support for this, particularly if you can't do it through reconciliation, and you're dealing with a 60-vote requirement. That puts a real damper on irrational exuberance," he said.

Miller also says a quick repeal is unlikely. "Even with the Affordable Care Act, with a supermajority, it took [the Democrats] a year and three months in reality once the president got into office to enact something," he said. "And they barely got it through with these political margins and then you were waiting another three and a half years for the real stuff to get put in place."

One thing both sides want to keep amid the changes is the subsidies, he said. However, they will likely be distributed differently, he added. Some people will get subsidies for the first time and others will see their subsidies reduced.

"A good bit of the insurance regulation rules will be harder to change," Miller says, "and they can't simply be quickly transformed through a budget reconciliation measure."

Medicaid Revamp

The talk among the GOP so far has centered on making Medicaid a block grant program, so states could have more say in who gets it and how much they get, which will mean a reduction in federal funding, fewer people covered, and fewer benefits over time, Doherty says.

Miller said he doesn't see a fixed-dollar block grant for each state but probably per capita allotments for parts of the program. He agrees, however, that, over time, federal allotments will be less generous.

People in the "old" Medicaid system will probably do better than those in the expansion Medicaid, he suggests, because one of the places from which money will be taken will be the expansion populations with a much higher federal match.

The future overall share of Medicaid will be traded off with opportunities through a tax-credit structure to "buy your way up" into private insurance coverage, he said.

Overall, he said about impending changes to the ACA: "The magnitude will be less than the folks opposed to the current law hope and won't be as drastic as those supportive of the law fear."

Doherty points out that changes to the ACA will be felt beyond insurance coverage. He says some groups who are authorized by the ACA that are now in the line of fire include the Center for Medicare & Medicaid Innovation and the Patient-Centered Outcomes Research Institute.

Mr Doherty has reported personal fees from the American Clinical and Climatological Association, outside the submitted work. Mr Miller has disclosed no relevant financial relationships.

Ann Intern Med. Published online December 13, 2016. Full text

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