On the first day of the new administration, President-elect Donald Trump has vowed, he will ask Congress to immediately begin work on a full repeal of the Affordable Care Act, also known as Obamacare.
The current president’s signature domestic policy, credited with helping about 20 million Americans gain health insurance coverage, including an estimated 1.6 million people in Florida, already has survived two Supreme Court cases and dozens of repeal votes by Congress.
With a Republican-controlled Congress and Trump’s promise to “repeal and replace,” the ACA might face its greatest threat yet. And though Republicans still lack the 60 votes needed in the Senate for a full repeal, Congress can use the budget reconciliation process to send a bill rescinding parts of the ACA to the president, as happened last year.
No matter the method, though, healthcare experts and economists say the effect of a repeal would depend largely on any new reforms and legislation adopted to replace the ACA.
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“That’s kind of the great unknown,” said Mark Rouck, a senior director with Fitch Ratings, a credit rating agency.
In a Kaiser Family Foundation poll measuring Americans’ views of the Affordable Care Act, 45 percent of adults said they held an unfavorable opinion of the law. The same ratio viewed the law favorably.
Americans remain divided on their opinion of the ACA, according to the nonprofit Kaiser Family Foundation’s “Health Tracking” poll, which has found that over the past two years more adults held an unfavorable than favorable view of Obamacare.
But parts of Obamacare also have strong popular appeal — such as prohibiting insurers from denying coverage for pre-existing conditions and allowing young adults to stay on their parents’ plans until they turn 26. Perhaps the least liked element is the individual mandate that every eligible adult must buy health insurance or pay a penalty.
The trouble with rescinding only the unpopular parts, however, is that those elements of the ACA work hand-in-hand with the more popular aspects.
For instance, the ACA could not require health insurance companies to take on all customers — including those with pre-existing conditions like cancer or asthma — without also mandating that every eligible adult buy coverage. Otherwise, only sick people would buy insurance when they needed it, which would increase costs for insurers, causing premiums to rise dramatically, and ultimately leading to bankruptcy for insurers.
But the ACA is bigger than the insurance exchanges where individuals can buy plans. It also includes provisions for states that choose to expand eligibility for Medicaid, the public health insurance program for low-income and disabled Americans, which has led to an additional 14 million people gaining coverage, according to government estimates.
Trump has proposed replacing the ACA with “a series of reforms ready for implementation that follow free market principles,” such as allowing the sale of health insurance across state lines and requiring price transparency from doctors and hospitals.
20M Number of Americans gaining health insurance coverage since 2010 under Affordable Care Act
Whatever replaces the ACA will need to preserve some of the law’s most popular parts, said Steven Ullmann, director of the Center for Health Sector Management and Policy at the University of Miami School of Business Administration.
“For Congress to do a total repeal, they will have to — very, very quickly and perhaps as part of repeal — put those elements back in,” Ullmann said.
With millions of Americans expected to sign up for an ACA plan during open enrollment, which began Nov. 1 and runs through January, the logistics of repealing Obamacare are also complex.
“To sign up for an insurance policy and then have that taken away in January or February, logistically, would be quite curious,” Ullmann said. “It’s unclear how that would occur and what it would mean to see the uninsured increase so quickly again with no access. That is something that would have to be addressed.”
The number of uninsured Floridians fell by 1.19 million from 2013, the year before the ACA exchange began, to 2015, according to a report from the U.S. Census Bureau. In South Florida, an estimated 487,000 people gained health insurance in that time.
In Miami-Dade, the uninsured rate in 2015 was 18.3 percent or about 488,000 — down from an estimated 600,000 who had no health insurance in prior years.
Repealing the ACA without an adequate replacement would turn back the clock on coverage gains, Ullmann said, and also raise the cost of healthcare. Uninsured residents would flood emergency rooms, unable to pay their bills, and hospitals would raise prices on insured consumers to pick up the difference.
In Miami-Dade, the uninsured rate in 2015 was 18.3 percent or about 488,000 people. In Broward, the uninsured rate was 14.5 percent or about 273,500 residents.
“That increases costs for insurers and that makes premiums go higher,” Ullmann said. “Those underlying factors don’t go away, they just get redistributed.”
Rouck, the Fitch Ratings analyst, said one possibility for an Obamacare replacement would be allowing insurers to sell health plans with fewer benefits than those required under the ACA, which mandates that all qualified plans must offer coverage for obstetrics, pediatric care and other services — even for single adults with no children.
Insurers also are prohibited from charging their oldest members more than three times the premiums charged to their youngest members, another Obamacare restriction that Rouck believes has led to financial losses for insurers and accelerated their retreat from the ACA exchange.
“There’s not a lot of flexibility in what they can do in terms of altering the benefits and the price,” he said. “To the extent they’re better able to alter that, it would improve their ability to be profitable.”
But it’s not just some insurers who are failing on the ACA exchange, said Seth Chandler, a visiting scholar with the Mercatus Center at George Mason University, which frequently issues reports critical of Obamacare.
To sign up for an insurance policy and then have that taken away in January or February, logistically, would be quite curious. It’s unclear how that would occur and what it would mean.
Steven Ullmann, health policy expert at University of Miami, on Obamacare repeal
Chandler, who has suggested that Trump deliver a “death blow” to Obamacare by rescinding some of the financial subsidies that make coverage more affordable, said rising premiums and the prevalence of high-deductible plans on the ACA exchange also made it more difficult for consumers to access healthcare.
“In some of those instances, the insurance that they got really did not meet their expectations and, in many instances, was not something where they would ever exceed the deductible,” he said.
Chandler believes the most likely replacement for Obamacare would be a blend of Trump’s healthcare platform and House Speaker Paul Ryan’s “Better Way” plan, which among other things proposes eliminating the ACA’s minimum benefit requirements and prohibiting denial of coverage due to age, income or medical conditions.
But he does not envision anyone advocating a return to the pre-2010 days before health reform. “There were definitely problems with the number of people who didn’t have access to good healthcare,” he said. “But I think we went down the wrong path.”