5 Things About Repealing and Replacing the ACA

During the December Managed Care Cast hosted by Patricia Salber, MD, MBA, of the Doctor Weighs In, the guest was Joe Antos, PhD, resident scholar at the American Enterprise Institute, who discussed potential changes to healthcare and the realities of repeal and replace under President-elect Donald J. Trump’s administration.

Here are 5 changes to healthcare delivery and the ACA that Antos discussed during his podcast.

1. Republicans are under pressure to repeal

Trump’s platform heavily featured promises to repeal the Affordable Care Act, although he didn’t talk much about replacing it. Now that Trump has won the presidency, the Republican party is going to face a lot of pressure to put their money where their mouth is and repeal the healthcare law as promised.

“Repeal doesn’t mean necessarily an immediate repeal,” Antos said. “Doesn’t necessarily mean repealing everything.”

2. Day 1 repeal bill seems unlikely

According to Antos, dreams from Republicans that there would be a repeal bill waiting on Trump’s desk for him to sign the first day he was in office don’t seem likely to come true. The reality of repealing the ACA is much more complicated.

“But certainly a repeal that repeals certain aspects of the ACA is feasible within a few months,” he said.

One part of the ACA that Republicans do want to repeal immediately is the individual mandate. So what would they keep?

3. Preserving parts of the ACA

Guaranteed issue and coverage for children on a parents plan until age 26 are both popular provisions that Trump has indicated he wants to preserve. But is it possible? The challenge is how to make guaranteed issue work when insurance companies still have to make money.

“We’re not going to go back to the days before the ACA when insurance companies could reject applicants for insurance or could restrict the kind of coverage they could get based on their health condition,” Antos said.

In addition, Antos feels that the coverage of young adults until age 26 was a poor provision that has backfired since the youngest, healthiest people in the country weren’t signing up for coverage on the exchanges.

4. The way to do penalties

According to Antos, the penalty for not signing up for coverage never should have been run through the government, because there would always be a lag between when a person chose not to sign up and when they were penalized. Another system of penalties and rewards could have been more successful.

The system Antos prefers is that insurance companies can charge people the fair actuarial rate, which will be more than the community rating, for 5 years if they haven’t signed up for coverage and weren’t exempted. But you also need to reward people for doing the right thing.

“I think a sensible thing to do as part of this scheme is to say, ‘Ok, if you sign up for coverage, you’re going to have a signing bonus,’” he said. “So this really applies mostly to people who are brand new to this market—and they’re going to typically be younger people.”

5. Difficult to take away Medicaid expansion

Once a subsidy has been granted it is difficult to take away, Antos explained. He expects CMS will grant more flexibility with waivers for states to shape the programs. The example is likely Healthy Indiana, which was created through the help of Seema Verma, MPH, who is Trump’s pick to lead CMS. The program has a work-search requirement for able-bodied individuals. He isn’t expecting many large changes to the Medicaid expansion programs.

“I think that many of the states that have not so far signed on will in fact take this as an opportunity to, frankly, get some more money for their states and for their providers with the ability to say that their expansion is moving in a more market-oriented way,” he said.