ACA Changes to Be Limited and Slow, Experts Say

Christine Wiebe

February 27, 2017

No one knows exactly what will happen to the Affordable Care Act (ACA) under President Donald Trump, but two experts are convinced that changes will be limited and adoption of those changes will be slow.

"The ACA was built with a set of benefits, costs, and revenue that are all interconnected," said Marc Boutin, JD, chief executive officer of the National Health Council, a coalition of healthcare organizations that advocates for patients. Altering the ACA is like playing a serious game of Jenga, he said: Pull out one piece and the whole framework could fall apart.

As a result, the fundamental structure is likely to stay the same, Boutin predicted. He presented his views at a recent program held by the American Diabetes Association in Washington, DC.

Although President Trump's rallying cry about the ACA has been to "repeal and replace" it, Boutin said a more likely outcome is "repeal and rebrand."

"We may end up with Trumpcare," he said, nodding to the ACA's nickname, "Obamacare."

Boutin repeated a joke that he said is circulating widely in the nation's capital, which demonstrates the level of confusion people have around healthcare reform: "People want to repeal Obamacare and replace it with the ACA."

Targets and Protections

Republican proposals that could replace the ACA have two broad goals: to cap federal healthcare spending and to offer more flexibility to the private sector and to state governments, said Kelly Brantley, vice president of Avalere Health, a healthcare consulting firm. She and Boutin shared the stage to present their insights into the reform process.

Because repealing the entire ACA legislation would require 60 votes in the Senate — where Republicans outnumber Democrats by just two — the reform process most likely will happen through "reconciliation," which requires only a simple majority of 51 votes, Brantley explained. To make up for easier passage, reconciliation limits any to provisions tied to money coming in or going out. Many sections of the ACA do not have a financial impact and thus could not be touched, she said.

She identified which provisions likely will be repealed:

  • Penalties for the individual and employer mandates to carry and provide health insurance;

  • Financial assistance provided through tax credits and cost-sharing subsidies;

  • Additional taxes, including the medical device tax, the health insurance tax, and the "Cadillac tax" on high-cost health plans provided by employers; and

  • Medicare tax increases for high-income individuals.

The following provisions are likely to stay:

  • Prohibitions for excluding individuals from insurance plans based on pre-existing conditions;

  • Coverage for dependent children until age 26;

  • Changes to Medicare provider rates, such as reductions to the "market basket" index that is used to set payment levels; and

  • Penalties for hospital-acquired conditions and for readmissions.

State Protections and Reforms

As for state Medicaid programs, Brantley said she does not believe any states that expanded their programs under the ACA will lose that broader coverage.

"It's hard to take insurance away," she said. What's more likely is that states will be given more flexibility to structure their programs to meet their different needs.

Boutin added: "There will be winners and there will be losers."

One opportunity will be to use states as incubators to test different approaches to insuring the poor, he said. An interesting approach would be to tie health coverage to other social needs, such as transportation and housing. "In this country we tend to treat all of those separate issues in silos," Boutin said. Programs that pull them together could lead to better outcomes at the same time as controlling costs.

Many state governors want to reform their state Medicaid programs, Brantley said. Some of the most common items on their wish lists are the following:

  • Medicaid premiums, to be paid by the individual;

  • Increased cost sharing;

  • Required contributions to health savings accounts; and

  • Program lockouts after a predetermined period, to motivate individuals to get jobs with health coverage.

But none of the changes will happen in the next couple of months, Boutin and Brantley agreed.

"I think this is going to be far less draconian than people originally thought," Boutin added.

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