Obamacare Future’s Not So Bright


What might the future hold for the U.S. healthcare system?

After the Longest, Strangest Presidential Campaign In History™, Donald Trump was named President-elect early Wednesday morning, and many credited the massive premium increases for plans in the Health Insurance Marketplace (exchanges) for helping his cause. Discussions among the policy lay and expert alike turned immediately to the fate of the Affordable Care Act (ACA), which Trump vowed to repeal and replace.

Though no one has a crystal ball, experience can at least outline which pieces must fall into place. 

Congressional Control Favors ACA Repeal
As important as having an ACA opponent being elected president, the Republicans retained control of the House and Senate, providing similar conditions the Democrats had when passing and approving the ACA. Though—unlike Democrats in 2008 to 2010—the Republicans do not have a 60-seat majority in the Senate to overcome a filibuster, they have already used reconciliation (the same legislative technique Democrats used to pass the ACA in 2010) to pass in January 2016 the Restoring Americans’ Healthcare Freedom Reconciliation Act of 2015 (H.R. 3672) before President Barack Obama vetoed it. H.R. 3672 would have repealed the ACA’s tax increases, Medicaid expansion, and exchange subsidies. 

And what should replace the ACA? This will require separate legislation and cannot be snuck in a reconciliation package. Many think this could offer an opportunity for a bipartisan solution; many Democrats now in Congress did not vote on the ACA and appear to be willing to make changes to improve it.

So the legislative path to repeal at least parts of the ACA is known, even if a replacement could take several forms. That, in fact, may be the easy and fast part. For example, 2 major structural changes wrought by the ACA—exchanges and Medicaid expansion—did not go into effect for 4 years after the legislation passed.

Favorable ACA Provisions
Multiple provisions of the ACA popular with politicians and consumers will probably remain in one form or another. One obvious example is the prohibition on exclusions for pre-existing conditions; another is allowing children under age 26 to stay on their parents’ health plan. Another is the shift away from fee-for-service payment schemes in favor of value-based payment approaches.

Potential Changes
Though the end product is unknown, many Republicans favor greater use of health savings accounts (HSAs) and plans that are more customizable to the insured than the comprehensive (many Republicans argue overly comprehensive) Essential Health Benefits package. Medicaid block grants are also seen as a possible path forward.

Drug Pricing Debate Not Going Away
Hard decisions and discussions still follow. The debate over drug prices will continue, though the threat of governmental intervention is considerably less with Republicans controlling 2 branches—at least until 2018. Nevertheless, politicians will still feel tremendous pressure from their constituents to lower prices or at least allow more transparency into pricing; as a result, government steps to ease the burden of high drug prices would not be a surprise.

The Republicans have been arguing for 8 years that their approach to healthcare would be better for individuals and the country. They may now have a chance to show it. Interesting times await. We’ll be here to keep you posted.


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