My students in the Executive MHA program at Florida Atlantic University often ask me, “What is the future of Obamacare?” and “What do you think Donald J. Trump has planned for health care?” While I do not have a crystal ball, there are a few (perhaps obvious) predictions we could make.
I think it’s important to understand, first of all, that Obamacare isn’t just one neat package. Often referred to as a “three-legged stool,” the viability of the Affordable Care Act (ACA) hinges on 1) the individual mandate, 2) requiring that insurance companies not base premiums on health status, and 3) providing subsidies for lower income citizens. The policy conceivably topples without all three legs intact. That said, the legs are wobbly. While the policy has certainly been a grand success insofar as it has brought our uninsured rates to the lowest point EVER IN HISTORY (which is kind of awesome), there remain many uninsured U.S. citizens, particularly in those states that did not expand Medicaid. Further, some insurers, including Aetna, Humana and United Healthcare, are choosing not to participate in certain marketplaces due, in great part, to revenue losses associated with covering enrollees who are sicker. Consumers are finding fewer choices, competition is reduced, and financial losses suffered by insurers are shifted to patients. Healthcare reform continues to need reforming. Not only are insurers taking a beating, but pharmaceutical cost containment measures were noticeably left out of the ACA and mental health parity remains in need of major overhaul.
But back to the question: What is the future of Obamacare? Honestly, I have no idea. There are so many economic, political, job market, health care needs, political, human values, and (did I mention?) political factors that could contribute to the policy’s failure or success. Speaking of, in case you had not heard, we have a very different president stepping into office in a couple months. His original campaign plan included complete repeal of the ACA (which would require an act of congress, FYI). He also proposed to modify law that inhibits interstate sale of health insurance, tax deduction of health insurance premiums, major promotion of health savings accounts, price transparency from health care providers, and incentives for drug companies to offer cheaper products (see https://www.donaldjtrump.com/positions/healthcare-reform).
Since winning the presidential race, DJT has modified his health care positions somewhat. A comprehensive overview of the current Trump plan is available at https://www.washingtonpost.com/news/to-your-health/wp/2016/11/17/the-ultimate-qa-about-health-care-under-president-trump/. He will more likely amend the ACA in such a way that would not require congressional involvement (smaller legislative moves and DHHS re-interpretation of the existing policy). Trump also stated in an interview on CBS’s “60 Minutes” that he would like to keep the pre-existing conditions regulation intact and continue to allow young people to stay on their parents’ insurance until age 26.
Trump is a free market guy and will likely attempt to utilize more competitive, rather than regulatory approaches to health care cost containment. Admittedly health care doesn’t really operate in a free market way, but some of his competitive approaches could be effective. For instance, it is possible that with more insurance companies competing, there could be slower growth in premium costs. The downside? According to a recent Commonwealth Fund analysis (http://www.commonwealthfund.org/publications/issue-briefs/2016/sep/trump-presidential-health-care-proposal), the Trump plan would increase the number of people who lack health insurance by as many as 25 million, and increase the federal budget by as much as $41 billion (due to tax breaks for purchasing insurance). Further, women are concerned about healthcare re-reform. Planned Parenthood could be fully de-funded and birth control may no longer be available for free. According to Cosmopolitan magazine “Women Are Urging Each Other to Get IUDs Now — Before It’s Too Late.”
It is most important to keep in mind that attempts at making major changes to our health care system will not come easy. As mentioned, the ACA is a wobbly, three-legged stool. For example, it is impossible to remove the individual mandate provision while maintaining that insurance companies offer plans regardless of preexisting conditions. Insurers are already struggling to insure sicker enrollees while also covering more wellness services without cost sharing by members. If the individual mandate were removed, the stool comes crashing down. Additionally, on a more theoretical note, American citizens (and most humans) are opposed to radical change. It will be in Trump’s best interest to tread lightly and make slow, small modifications.
I know this is a lot to consider, but the truth is, we will not know details of Trump’s health care intentions for some time. What we do know is that health care is likely the single greatest drag on our economy and we, as health care professionals, must all participate in influencing our legislators to address health care with utmost seriousness.
If you enjoy discussions like this, I encourage you to check out the Executive Master’s in Health Administration program at Florida Atlantic University. We tackle the big issues!
