Republicans have long aimed to repeal Obamacare, and with control of the Legislature and White House now, this is likely to happen. Health care columnists for the New York Times Aaron E. Carroll and Austin Frakt have discussed the possibilities — the practical and the political. A summary of their remarks is covered below:
Austin: Though Republicans could hypothetically change their minds, they claim to want to repeal portions of the Affordable Care Act very soon after Trump takes office. They would target key parts like premium and cost-sharing subsidies; the individual mandate; and various taxes that have funded the expansion of coverage.
Yet rather than repealing these right off the bat, they will likely delay the repeal so it takes effect a few years from now. This would buy them the time to develop a replacement plan – maybe even with the involvement of Democrats, though remains quite uncertain.
To many, that may seem like a prudent course of action: delay major changes to give time to provide alternate ways for people who currently depend on Obamacare to get health insurance.
At the same time, such a delay is also necessary, because congressional Republicans do not yet agree on any given replacement plan. And developing any coherent replacement plan will involve complicated policy trade-offs and political risks, making it a long time, potentially, for things to come together.
Aaron: The cautionary stance here goes even further. No proposal for repealing the A.C.A. so far has managed to avoid massive disruptions to health insurance. Such disruptions can be highly unpopular. Republicans aren’t going to want to see an electorate mobilized like it was during the 2010 midterms following the passage of the A.C.A.
Delaying any changes until 2019 or later means that no changes would go into effect until after the 2018 House and Senate elections. Americans wouldn’t yet feel the pain of having to change insurance or providers. Republicans could go into their campaigns claiming that they honored their promises to repeal Obamacare without actually having to deal with the real-world repercussions. Potentially, they could also claim a mandate for continued change if they were able to retain power.
This doesn’t differ much from the Democrats delaying implementation of much of the A.C.A. until after the 2012 presidential election. Of course, that didn’t protect them from the backlash they saw in 2010. No one can predict if delaying action would entirely shield Republicans either. And there are many more potential downsides from this plan.
In terms of downsides, here are a few that come to mind. First, insurance companies thinking about marketplace plans may be skeptical about whether the investment is worth it. If the A.C.A. is scrapped — and whatever replaces it unknown — they may opt to simply wait and see. Similarly, insurers currently offering plans could conclude that it’s not worth continuing to do so since no one knows if there’s even a future in it.
Hospitals will certainly have concerns about a potential increase in uninsured patients who can’t afford to pay for service. Such an outcome would certainly come to pass under repeal and remains likely under the types of replace plans Republicans are considering, which would include fewer people.
Drug and medical equipment companies will also have reservations about potential loss of revenue if a smaller population is covered in the future, resulting in decreased care and prescriptions.
Finally, states that expanded their Medicaid programs might withdraw in face of the risk of being left with the full costs of expansion after repeal goes into effect. Moreover, states that didn’t expand are more likely to hold off. Once again, why would someone invest in a program that’s going away?
Aaron: It’s the drawbacks for patients that are probably being ignored most of all. Clearly these changes would be detrimental for insurance companies, hospitals and drug companies. But how about the 20 million people at risk of losing insurance overnight if repeal kicked into gear without a replacement plan in the queue?
We could even see a scenario where people delay big life decisions until this is resolved. Some women with Obamacare could delay pregnancy if a chance remains for them to lose their insurance (especially if pregnancy goes back to being a “previously existing condition” and prevents them from getting on a new plan. In fact, it’s not unreasonable to expect a noticeable impact on the birthrate in the U.S.
Austin: Many agree that even repeal with delay would be highly disruptive, and possibly hurt health care markets and consumers. If that prediction is correct — and many others are predicting the same — is there a chance Republicans won’t follow through, or that they’ll wait for a replacement plan before repealing?
Aaron: “I really can’t see them waiting long to pass something. They’ve been campaigning on this for so long that I think they probably feel they have to act pretty fast. There’s so much work needed to get a replacement plan done, scored and passed that I think something like repeal and delay is a real possibility.”
Aaron E. Carroll is a professor of pediatrics at Indiana University School of Medicine who blogs on health research and policy at The Incidental Economist and makes videos at Healthcare Triage. Follow him on Twitter at @aaronecarroll. Austin Frakt is a health economist with several governmental and academic affiliations. He also blogs at The Incidental Economist, and you can follow him on Twitter at @afrakt.