ACP, specialists examine the future of the Affordable Care Act

As inauguration day for President-elect Donald J. Trump looms, the future status of the Affordable Care Act remains uncertain. The ACP and several specialists offer insight on what would happen to the nation’s health care if the Trump administration’s plan to repeal and replace the current law is carried out.

 

In a recent letter to the House of Representatives and the Senate, the ACP urged Congress to preserve protections established by the Affordable Care Act (ACA) and to determine the impact of proposed changes to the ACA on coverage, access and protection for patients.

 

“Independent and non-partisan analyses show that efforts to ‘repeal and replace’ the ACA would lead to massive losses of coverage and consumer protections for people enrolled in commercial insurance markets and in the Medicaid program, slow the movement to value-based payment reforms, force seniors to pay more for their prescription drugs, and undermine initiatives to prevent illnesses and promote public health,” Nitin S. Damle, MD, MS, MACP, president of ACP, said in the letter. “If the ACA is repealed, every state in the country would experience big increases in the uninsured rate, uncompensated care, and potential loss of coverage for people with pre-existing conditions.”

 

The ACP highlighted several studies from the Congressional Budget Office and the Urban Institute that predict that a repeal of the ACA would increase federal budget deficits by $137 billion between 2016 and 2025 and withdraw insurance coverage from approximately 58 million Americans. In addition, 52 million Americans aged younger than 65 have a pre-existing condition that would have likely led to them not being covered in the insurance marketplace prior to the implementation of the ACA, according to a study from the Kaiser Family Foundation.

 

“Our sincere hope is that Congress will join with physicians, nurses and other health professionals; consumer and patient advocacy groups; hospitals; insurers; states; employers; and others to consider approaches that will result in improvements compared to current law in coverage, access, and protections,” Damle said in the letter. “Especially for lower-income patients and those with pre-existing conditions and chronic illnesses, rather than rolling them back.”

 

Moreover, President Barack Obama, JD, recently warned that it would be “reckless” to repeal the ACA without a replacement in the New England Journal of Medicine.

 

Several experts also provided their opinions on the proposed repeal and replacement of the ACA in editorials published in Annals of Internal Medicine and JAMA.

 

According to Gail R. Wilensky, PhD, of Project HOPE, the House Republicans’ “Better Way” proposal is the most developed replacement plan of the ACA.

 

“This plan includes several of the traditional Republican proposals that the president-elect has also supported, such as expanded use of health savings accounts, high-risk pools, and allowing the purchase of insurance across state lines,” Wilensky wrote. “The plan also replaces existing premium subsidies with a refundable tax credit, which would be available to individuals not covered by Medicare, Medicaid, or employer-sponsored insurance.”

 

Such a replacement plan could eliminate “essential” health benefits, causing, for example, those with serious mental illnesses to lose coverage even if those plans supposedly “covered” individuals with preexisting conditions, according to Susan Dentzer, BA, president and CEO of the Network for Excellence in Health Innovation in Cambridge, Massachusetts. In addition, she argued that the replacement of guaranteed issue would only offer coverage to those with preexisting conditions who stayed continuously enrolled in health coverage, forcing them to pursue expensive coverage through “high risk” pools if they lost their coverage.

 

“Failure to ensure a sustainable risk pool could trigger a ‘death spiral’ in the individual and small business insurance markets,” Lawrence O. Gostin, JD, of Georgetown University Law Center, and colleagues wrote.

 

Repealing the ACA also jeopardizes demonstration projects for effective alternative payment models, many of which are supported by CMS’ Innovation Center, according to Gostin and colleagues.

 

The plans of the Trump administration to repeal the ACA without a definitive replacement plan has the potential to dangerously impact the nation’s health care, as crafting a new plan could take several years, Dentzer argued. While the ACA has imperfections, it allowed approximately 20 million Americans to obtain comprehensive, meaningful and reliable health care coverage and reduced the overall rate of uninsured Americans to a historic low at 8.9%, she wrote. She also noted that an American Hospital Association study found that a repeal of the ACA would cause many Americans to lose coverage, as well as access to their prescribed care regimen, resulting in “an unprecedented public health crisis.”

 

“In truth, no extant Republican plan has assembled a suite of insurance provisions, subsidies, Medicaid coverage, and other assistance that would offer as much protection as the ACA,” Dentzer wrote. “America's physicians need to resist repeal and demand to see a full-blown replacement plan first, with the same cold-eyed rigor they would apply to any claim that the latest snake oil offering on the market was a better cure for patients.”

 

Furthermore, many of the changes that the Republicans want to implement could probably be accomplished by amending the ACA rather than repealing it, according to Wilensky. “However, the political imperative for Republicans to be able to claim they have ‘repealed the ACA’ may push them to pursue that route,” she claimed.

 

“Repealing some or most of the funding for the ACA would be relatively easy to accomplish. But ensuring that 20 million newly insured individuals retain coverage will be more challenging,” Wilensky wrote. “Moreover, it is unclear if the market-oriented reforms in the Republican plan will be any more successful in making health care more affordable for U.S. residents than the ACA has been.”

 

Overall, the purpose of modifying or replacing the ACA should be to ensure that all individuals, whether sick, healthy, poor or wealthy, obtain the health care that they require, according to Gostin and colleagues. – by Alaina Tedesco

 

References:

Dentzer S. Ann Intern Med. 2016;doi:10.7326/M16-2935.

Gostin LO, et al. JAMA. 2016;doi:10.1001/jama.2016.18908.

Wilensky GR. JAMA. 2016;doi:10.1001/jama.2016.18762.

 

Disclosure: Denzter is affiliated with NEHI. Gostin and colleagues do not report relevant financial disclosures. Wilensky reports receiving support from the United Health Care and Quest Diagnostics.