So what will Trumpcare look like?
Doctors, hospitals, insurance agents, employers and average folks are wondering how President-elect Donald Trump’s campaign pledge to “repeal and replace” the Affordable Care Act will play out in the real world of government and health care.
None of them yet knows for sure; these are early days. But the incoming president did show signs he may moderate his position after his first meet-up with President Barack Obama last week. In his first interview with the media Friday, he told the Wall Street Journal he would consider retaining parts of the act. Specifically, he said he favors keeping the popular prohibition against insurers denying coverage to people with pre-existing health conditions and the ability of parents to keep their children on their insurance plans until age 26.
After a bit of discussion we’ll outline the changes that could take place, most likely for 2018 because most people’s health plans are already in place for the coming year.
The new administration and Congress have a chance to improve the health insurance system without causing serious disruptions, said Chuck Olson, CEO of OCi Insurance and Financial Services of Omaha, which provides services for insurance agents.
“I think you’re going to find that the administration puts together a very good think tank that decides how to unravel the mess that’s there right now,” Olson said. “We can have options that will allow people to purchase the plan that makes the best sense for them and their families.”
For example, Olson said, to encourage people to sign up for insurance, “instead of a stick, use a carrot. Allow people to take deductions for their health insurance.”
Right now, under Obamacare, people are required to have insurance or they are charged a penalty — the stick, in Olson’s analogy.
Dr. Cliff Robertson, chief executive of Omaha-based CHI Health, said the president-elect has shown an ability to follow through.
“If he says he’s going to find a way to repeal and replace, I would not want to underestimate that,” said Robertson, whose company runs Bergan Mercy, Immanuel and other local hospitals. No matter what happens, he said, the pressure will remain to deliver health care that’s less costly.
“We’ve got to be more efficient, more effective, because nobody can afford us as it is today,” he said.
Chris McPike, a vice president with the Lincoln insurance brokerage ComPro, has been working with a 50-something couple — a self-employed husband and at-home wife with three high school- and college-age kids — who are facing a $2,600 monthly premium for a mid-range health plan.
That needs to change, McPike said, but “I want people to not be so eager to repeal that they fail to construct a suitable alternative.”
After all, even with possible flaws, the Affordable Care Act has insured some 20 million people, including those added to Medicaid in some states, who didn’t have coverage before. It’s not likely that changes would be so dramatic to throw those people out of insurance coverage. Any changes will have to take into account those people.
“All of the warts of the Affordable Care Act aside,” said Dr. Dan DeBehnke, CEO of Nebraska Medicine, “it (provides) important coverage for millions of Americans. To quickly repeal it would leave millions without coverage, and that would be a political nightmare for the president-elect.”
DeBehnke said a first step for the new president will be to fill key health care-related Cabinet positions and start working with Congress.
He said House Speaker Paul Ryan is well-respected in the health care arena and has some “really good thoughts” on health care reform and policy. Sen. Mitch McConnell, R-Ky., the Senate majority leader, and Sen. Charles Schumer, D-N.Y., the incoming Senate minority leader, are seen as across-the-aisle dealmakers.
“There are some good people in Washington who are poised to work across the aisle and make things work,” DeBehnke said, but change must be done carefully.
Major changes would require support from Congress, including the Senate, where Republicans have a majority but not the 60 votes needed to overcome possible procedural issues, like ending a filibuster, said Dr. Rowen Zetterman, an associate vice chancellor at the University of Nebraska Medical Center.
Even with congressional support, changes in government programs take time. Repealing the law would mean changing all the regulations written since the law was passed in 2010, a process that requires public comment and possibly hearings.
The law also is embedded in the federal tax code and social services system.
There is widespread support for universal access to health care and portable coverage for all, principles doctors have been supporting for years, said Dr. Robert Wergin, a family physician from Milford, Nebraska, and immediate past president of the American Academy of Family Physicians.
But the law as it stands is unsustainable because of the limitations on the plans companies can offer, said Dr. David Filipi, a retired Blue Cross Blue Shield executive and past president of the Nebraska Medical Association.
Among the cost imbalances he cites: Younger, healthier people are charged too much and, as a result, aren’t buying in. Older, sicker people are getting good deals but forcing up costs and prices.
Details of Trump’s proposed changes are few. The transition team issued general statements about replacing the ACA and improving health care, but some points seem contradictory, such as returning health insurance regulation to the states but letting people buy health insurance across state lines.
So far, Nebraska Insurance Director Bruce Ramge said last week, there has been no word of changes from the Center for Medicare & Medicaid Services, the federal agency that runs the Affordable Care Act.
“We are monitoring it like everybody else,” Ramge said. “I can’t really predict what will occur because there are so many moving parts.”
DeBehnke, from Nebraska Medicine, is sending a video to staff that, among other points, urges cooperation with the coming administration. Nebraska Medicine’s mission, he said, won’t change. The changes will happen around it.
If the government acts, those in the industry say, here are some things that could change and some that could remain:
People can’t be denied coverage because of “pre-existing conditions” under Obamacare, but some have gamed the system through “special enrollment periods,” buying insurance only when they are about to have expensive surgery or treatments.
That could be replaced with a system that requires insurance companies to accept people who have had insurance but would allow health screening for those who haven’t, as in the past. People who are too sick for an insurance company to assume the risk would be offered coverage through high-risk pools, funded by all insurance companies, a method Trump’s transition team says is “proven.”
A centerpiece of the legislation, the online sites let people browse for health plans and determine whether applicants qualify for incentives to reduce their costs. Opponents view the exchanges as an unnecessary step in getting people insured.
The exchanges could close, letting insurance companies offer plans and determine who qualifies for incentives. The Internal Revenue Service already has the final say on the tax incentives.
The government could come up with another way to help pay for insurance for low-income people, possibly through tax credits to insurance companies based on family size and income.
Penalties haven’t forced everyone to buy insurance anyway and could be dropped. Instead, the government could let people deduct their health insurance premiums, which would make their coverage cheaper.
People could remain uninsured even though health care providers end up with charity care costs that are passed on to people who do have insurance.
The ACA’s set of required coverages — such as maternity benefits in plans for older men, which was a target for critics — could end, as would the bronze, silver and gold benefit levels.
Instead, insurance companies would design plans they think people would buy. People who want top-flight coverage would pay for it; people who want minimum coverage would pay for that, too, taking the risk that they might have to pay big medical bills.
The ACA sent grants to nonprofit groups to train people to help clients enroll in health plans and qualify for tax subsidies. The function could go away, letting people sign up for health plans online through private exchanges or insurance company websites, or through insurance agents.
Available before the ACA, the accounts let people put aside money for future medical costs. Trump endorsed the concept, and the government could encourage the practice through tax policy or by limiting alternatives.
Few people have objected, and the cost isn’t high. The rule could be retained, keeping millions of healthy people within the insurance pools.
Allowing such policies could let some people save on their premiums.
Under the ACA, insurance companies must pay claims totaling 80 cents of every dollar of premium they receive or refund the extra cash, a provision designed to prevent price-gouging.
But the rule meant companies could make more money by paying more claims, reducing the incentive to seek lower costs.
Ending the rule would encourage insurers to drive down costs so their profits would increase. What would prevent gouging? Competition.
Health care providers, insurers and the government likely will continue working on ways to improve, which also can cut costs. That may include some of the pilot programs started under the ACA, as well as encouraging private industry’s efforts at making care costs transparent and other improvements.
They haven’t worked well, and those still in business could be phased out or converted to for-profit groups.
Such a bill was introduced, passed and vetoed, and could be reintroduced.
Some spending could end right away, but the bulk of the spending is already committed. That means people who have signed up for individual coverage in 2017 will receive the tax incentives they have been promised.
What would end? For example, last week the government awarded $1,068,804 to Nebraska groups for “activities related to planning and implementing selected federal market reforms and consumer protections.”