The Affordable Care Act (ACA) has been integrated in stages for nearly seven years, with most of the policies in effect having been executed over the last three. Repealing and replacing it is a monumental task.
Republicans have already designed many alternatives in the last few years, but none of them made it past the Senate majority or President Obama. However, with the combination of a Republican Congress and President-elect Trump, the ACA’s days may be numbered.
Trump met with President Obama shortly after the election and made a statement regarding key provisions of the ACA that he now intends to keep. Preserving the policy that allows young adults to stay on a parent’s health insurance plan until age 26, and the ban on denying coverage to those with pre-existing conditions, means a full repeal has been set aside. But the Affordable Care Act will be completely transformed, and many people stand to lose their current health plans.
Prior Republican legislation indicates a two-year time frame to establish Trumpcare’s system of tax credits and health savings accounts (HSAs) for individuals, the modernization of Medicaid and the creation of a free-market enterprise for health insurance and pharmaceutical companies. These plans are designed to encourage competition and lower costs throughout the health care industry. Options for replacement should be offered by 2019.
In late 2015, the CBO estimated that about 22 million people would have lost health insurance after the end of 2017 if the GOP’s legislation HR 3762 had been enacted. These would have been people covered through Medicaid and the insurance marketplaces.
The Committee for a Responsible Federal Budget followed in 2016 with an estimate of almost 21 million people losing their insurance coverage. They believe Trump’s replacement plans would cover just 1 million of the 22 million individuals expected to sacrifice benefits under the ACA repeal.
The Rand Corporation shows that the combined effect of Trump’s proposals would leave 20.3 million uninsured. It’s clear that around 20 million people would lose their current health benefits under the law if the ACA gets repealed, and Trump does not appear to have an adequate explanation for how those affected would be covered under his version of national health care.
Lower-income individuals would be more affected than others when the Medicaid expansion is repealed along with the ACA. It covers 15.7 million additional people with incomes below 138 percent of federal poverty level, a provision added in 2013. A Republican administration will focus on getting people off of Medicaid subsidies and into private plans with tax credits to help cover the premiums.
Trump wants to replace current funding for low-income individuals to each state using block grants or per-capita allotments to supplement their own programs. This transition will not likely happen until 2018 or 2019.
If the estimates overall are roughly 22 million, and 15.7 of them are subsidized by Medicaid, that leaves about 6.3 million marketplace enrollees without their current coverage once the exchanges get dismantled under Trumpcare. However, there are many unknown variables regarding the replacement plans and the success of tax cuts, credits and deductions applied to the purchase of health savings accounts. The details of changes to Medicare and Medicaid could have wide-ranging effects on estimates in either direction.
Avik Roy, president of the Foundation for Research on Equal Opportunity, along with several economists, came up with vastly different numbers based on three different but very specific proposals for repeal and replacement. The Patient CARE Act would only reduce coverage by 3 million people, A Better Way would reduce coverage by 2 million, and Roy’s own proposal claims to increase the number of insured by 9 million.
The particulars of Trumpcare can greatly change the outcome; we might end up somewhere in between. For the 20 million or more Americans who count on the ACA for coverage, their future depends on those particulars.