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The words "repeal and replace" were thrown around during the campaign, but the reality is much more unclear for government officials.
The effort to repeal and replace the Affordable Care Act (ACA) is like the game Jenga, in which players must carefully pull blocks of wood from within a tower and place them on top without the whole thing collapsing.
Republicans in Congress and the Trump Administration want to remove some unpopular elements of the ACA, such as the individual mandate, leave others in place, and avoid having the whole individual insurance market collapse. Physician groups are watching nervously from the sidelines and urging the Republicans to retain key elements of the ACA. They also are trying to gauge what the impact of a repeal would be on their patients and practices.
With no clear consensus plan in place yet, new replacement proposals were being floated almost daily in late January. One would allow states to choose whether to keep or jettison the health insurance exchanges. There is one thing John Meigs Jr., president of the American Academy of Family Physicians, is sure of: "If they repeal the ACA without anything to replace it, it is going to create real problems," he says.
"In primary care, we still see the patients who don't have insurance," Meigs explains. "We take the loss or do some kind of discounted fee schedule to try to accommodate them. But it is extremely difficult to get an uninsured patient in to see a specialist." Also the ACA has significantly increased the number of people accessing preventive services such as mammograms and colonoscopies that they had been putting off. "Now they could go back to putting those off again," he says. "It could have a snowball effect."
Meigs pointed to a 2016 study by the Urban Institute and Robert Wood Johnson Foundation, which found that providers would be on the hook for more uncompensated care if the ACA were repealed.
The report estimates that the providers' share of uncompensated care would increase 109.2 percent in 2021 if the ACA were repealed, from $21.3 billion to $44.5 billion.
Why Crafting a Replacement Is So Difficult
Anne Phelps, principal and U.S. healthcare regulatory leader for consulting firm Deloitte, says she doesn't think replacement legislation will come in a single 2,500-page bill. "It is more likely to be a series of steps in terms of the budget process and regulatory changes." Republicans are talking about providing a base level of coverage - a revamped high-deductible/health savings account (HSA) plan with catastrophic coverage and lower premiums, she says.
Upon taking office, President Donald Trump immediately issued an executive order that instructed the U.S. Department of Health & Human Services to use its authority to begin scaling back ACA rules, including how hardship exemptions to the individual mandate are granted and allowing states to charge more fees to Medicaid enrollees.
The problem for his administration and Republicans in the U.S. Congress is that insurers have relied upon the individual mandate and government premium subsidies to offset the cost of covering people with pre-existing conditions. Insurers could be unsettled by the prospect of changes even if they are delayed a few years. Their participation in the individual insurance market is optional, and their plans and prices have to be set months in advance of when they are sold to consumers, explains Sabrina Corlette, a research professor in the Center on Health Insurance Reforms at the Georgetown University Health Policy Institute.
Any policy change that asks insurers to come up with plans or prices for 2018 without knowing in advance what the rules of the road are going to be sets the stage for them to either (a) decide it isn't worth it and focus on other lines of business (Humana, a large insurer based in Louisville, announced recently that it's dropping out of Obamacare exchanges in 2018, citing the tenuous marketplace) ; or (b) choose to participate but raise their premiums to account for the higher level of risk associated with the uncertainty, she says. In either of those scenarios, the downstream effects are going to vary from market to market, Corlette said. "You may have some pockets that remain viable, where consumers are still going to be able to buy coverage, but you may have other parts of the country where they are not. Insurers are raising big red flags to Congressional leaders to say, 'If you repeal the individual mandate and the subsidies, with or without a transition period, these markets are going to crater.'"
During his campaign for the White House, President Trump stressed that allowing insurers to sell policies across state lines would increase competition and bring premiums down. But most observers who study the insurance markets say the effect would be negligible. "That is a nice pipe dream. That sounds like a nice campaign promise," Meigs said. "But now we have to get down to reality."
Politicians like the idea of selling across state lines because it sounds like they are going to get rid of expensive regulations and standards that are driving up the cost of premiums, Corlette says. But the real drivers of premium increases are medical and pharmaceutical expenses, she adds.
Another problem is that provider networks are fundamentally a local issue. It is very difficult for insurers to break into a new market and form relationships with provider networks.
"Nobody in the insurance industry is lobbying for this," Corlette says. "We researched six states that had enacted across-state-line legislation, and none of them had a new carrier coming into the market because of that."
Advocating for Patients
Deloitte's Phelps said physician groups are concerned about making sure that not only is there stability in the market, but also that individuals, notably the nearly 9 million enrolled in exchange plans and the nearly 10 million enrolled under Medicaid, have access to coverage.
But Phelps adds that many physician organizations understand that repeal is likely to happen, so they have switched their focus to what a replacement plan should look like, including the balance between federal and state, where dollars should go with the credits and subsidies, and what to do about the Medicaid population.
Many physicians are voicing concerns about what might happen if the ACA is repealed without a replacement plan that allows consumers to find comparable and affordable insurance.
"I have taken care of patients prior to the ACA and I have taken care of patients afterwards and I have seen so many examples of the difference," says Mona Vishin Mangat, who has an allergy and immunology solo private practice in St. Petersburg, Fla.
She recalls one patient with severe asthma she has been seeing for close to 10 years. Prior to passage of the ACA, he couldn't afford medication or tests. Once the exchange opened, he got insurance and was able to get all the medications he needs and hasn't been in the hospital for three years.
"He was just in my office last month, and we were talking about what we are going to do if the ACA is repealed," she says. "There is a lot of disbelief among patients that it is going to happen. But it is a very real fear among patients and physicians."
Mangat, who is active with a pro-ACA advocacy group called Doctors for America, said it is rewarding to her professionally when insurance coverage is not a limiting factor in her treatment of patients.
She also thinks about it from business standpoint with four employees on exchange plans. "It is a wonderful thing to know your employees can get the care they need," Mangat says.
She is skeptical of Republican proposals to expand access through plans with high deductibles and HSAs. "HSAs are fantastic for people who have money," she said, "but if you make $10 per hour, there isn't going to be money in that health savings account," she said. "And with high deductibles, often chronic conditions do not get cared for. You don't take care of your asthma until you have to go to the hospital; you don't take care of your blood pressure until you have a heart attack."
It is clear that Republicans are grappling with the reality that they have to come up with something to replace the ACA. "I thought it was interesting when Trump, as president-elect, said he wanted universal coverage," Mangat says. "I'll sign up for that. Our patients need access to care."
So what should physician practices be doing to prepare for the changes ahead? Munzoor Shakih, director in the healthcare practice at business and technology consulting firm West Monroe Partners, says the economic realities of healthcare are much stronger than any of the political noise we are hearing now.
"It is easy to get caught up in the changing dynamics and uncertainty of it all," he says. "My advice is don't get caught up in it, because whatever happens we will still have to deal with a population that is aging and not very healthy. I would tell physicians' practices to stay the course in terms of preparing for those economic forces: get ready for bundled payments, cost containment, care coordination, and providing a superior patient experience."
If the new administration and new Congress want to pass a resolution to say they repealed Obamacare and then fix some of the ACA's problems so that they can now call it Trumpcare, McConnellcare or Ryancare, that's OK with the AAFP's Meigs.
"I don't care what they call it," he says, "as long as they take care of our vulnerable populations."