The Future of the ACA and US Healthcare Under President Donald Trump

As the Republicans retained control of both the House and the Senate and Donald J. Trump was declared the next president of the United States, it became abundantly clear that President Barack Obama’s landmark healthcare reform legislation was in grave danger.

The Affordable Care Act (ACA) is likely facing some sort of repeal, although it is not clear if the GOP will get rid of the entirety of the health law, according to health economist Austin Frakt, PhD, who is also the creator and co-manager of The Incidental Economist and has appointments with the Boston VA Healthcare System and Boston University. Frakt is also an editorial board member of The American Journal of Managed Care.

What the Republicans do with the ACA actually depends on if the party does away with the filibuster, he explained. With the filibuster in place, the Republican Senate just has to get any budgetary changes, such as changes to subsidies, through the budget reconciliation process, which can be passed with a majority vote. However, other aspects, such as the guaranteed issue, are not budgetary and so cannot be changed through that manner.

“If they want to do away with the filibuster, which is possible and has been threatened before, they can do anything they want, including a full repeal,” Frakt said.

Ultimately, he expects the future of the ACA to come down to how Republicans view the budget impact of the law and any aspects of it that they repeal. Part of Obamacare saves money, and the GOP could decide to keep those parts in the interest of doing something that is budget neutral or even budget saving, he explained. It’s important to note that since the Congressional Budget Office scores the ACA as saving money overall, repealing it entirely would mean running up the deficit.

Since it’s unclear at this time what the GOP would replace the ACA with, there are no clear numbers on how the uninsured rate would change or how healthcare spending growth will shift.

“Overall, we should expect fewer people covered and less spending on healthcare from the government under any kind of replace,” Frakt said.

One aspect of healthcare in the United States that will likely be safe is Medicare Advantage, which is a private provision of the Medicare benefit and tends to be more highly supported by Republicans. Plus, the Medicare Advantage program is already doing well under the payment rate cut that took place under the ACA.

On the flip side, health services research is on the chopping block. Historically, Republican administrations and members of Congress have been less favorable to supporting research and have cut agency funding for those things. One of Frakt’s fellow writers for the Incidental Economist identified what he thought could be the first budgetary cut.

I do not expect that AHRQ with survive.

— Bill Gardner (@Bill_Gardner) November 9, 2016

“I think we are looking at a period of belt tightening in research, and that’s going to be troubling for a lot of people and career threatening for many,” Frakt said.

Although he expects the ACA to be undone and cuts in research to be made, Frakt added that the next few years will likely be an environment of large health policy change. He will keep an eye on the implications of the change and who—meaning both individuals and industries—will benefit and who will be harmed.

He emphasized that it’s important to remember that the ACA and healthcare policy affect millions of people’s lives and large industries. A lot of the work being done by hospitals and providers over the last several years could be completely undone by the outcome of this election.

“It could be very, very disruptive and not just for people who have Obamacare plans, but for the whole industry and everyone who relies on it,” Frakt said. “Remember how big this is—a sixth of the economy is healthcare, and everybody touches the healthcare system in some way.”

UPDATE, 11/11, 5:28 pm: In an exclusive interview with The Wall Street Journal, the president elect admitted he is softening his stance on Obamacare after his meeting at the White House with President Barack Obama. According to the article, Trump has revealed he would be willing to compromise and keep 2 provisions: the ban on insurers denying coverage because of pre-existing conditions, and allowing children to stay on their parents' health insurance for additional years.