In anti-Obamacare circles, “repeal and replace” has for years been the conservative motto by which opponents of the U.S. health-care law operated. But vowing to repeal it was easy — the challenge was resolving what to replace it with.
Georgia congressman Tom Price, named by president-elect Donald Trump to head up Health and Human Services, believes he has some answers.
The nomination of Price, who objects to federal funding for Planned Parenthood and wants lawmakers to overhaul Medicare into a system of vouchers “within the first six to eight months” of Trump’s administration, signals what health care might look like in the new Trump administration.
So far, that looks like it’s a target on the existing health law also known as the Affordable Care Act (ACA).
‘Personal responsibility’ health care
Harvard School of Public Health professor John McDonough is bracing for health care to be viewed through a more conservative “personal responsibility” prism, resulting in the loss of essential protections for what he projects to be more than 100 million Americans.
“Some people have been saying that maybe Donald Trump is moderating his views [on repealing Obamacare], that he’s sending mixed signals,” McDonough says. “This appointment of Tom Price sends a crystal-clear signal.”
Price’s 242-page Empowering Patients First Act advocates for tax-sheltered health savings accounts and so-called high-risk insurance pools, and offers tax deductions or credits to help Americans buy the coverage they want.
But Democrats worry that patients in lower-income brackets could face steeper insurance and care costs.
“Not just higher prices, they’re going to face the loss of coverage,” McDonough adds, noting that Price’s legislation would eliminate Obamacare’s expansion of Medicaid, the social health-care program for lower-income Americans.
‘Not just higher prices, they’re going to face the loss of coverage.’ - John McDonough, Harvard School of Public Health
Around 14 million of the estimated 20 million people who gained coverage under the ACA did so due to the expansion of Medicaid.
Trump and Price share a plan to dramatically cut federal Medicaid spending and convert it into a federal “block grant,” meaning states would be provided with a fixed amount of money to decide how to cover a population’s health costs.
Chris Jacobs, a Republican health policy analyst, says that choosing Price, a longtime member of Congress, signals “that [Trump] expects legislative activity early next year,” and that Price will be well positioned to influence former congressional colleagues to back the administration’s priorities.
A conservative health plan would streamline costs, “rather than layering on government-imposed mandates and subsidies,” Jacobs says.
Help for higher-income Americans
Price has been an outspoken critic of Obamacare, and his legislation is aimed at cutting government out of health-care decisions that he says should be made between patients and doctors.
Price’s plan “would make health insurance more affordable for higher-income people who in the individual market now don’t get any assistance at all,” says Tim Jost, who teaches health law at the Washington and Lee University School of Law in Virginia.
The legislation would put a cap on the tax deductions employers could make for providing employee health insurance, which affects more than 150 million Americans. This would be designed to encourage companies to limit coverage.
The Price plan also advocates for the expansion of health savings accounts — tax-sheltered funds that allow Americans to sock away money to eventually dip into when they need to pay their deductibles out of pocket.
Jost, who uses a health savings account, says the mechanism primarily benefits higher-income families.
The Price plan would undo the Obamacare provision that prevented insurers from denying coverage to people with pre-existing conditions. Price’s bill would insure people with pre-existing conditions who are able to maintain “continuous coverage” 18 months prior to choosing a new policy.
Price’s proposal would do away with the ban on medical underwriting to assess health status. In its place, Americans with pre-existing conditions would have the option of going into so-called high-risk insurance pools that utilize the purchasing power of many individuals so that one person’s adverse health status doesn’t dramatically change anybody’s costs.
Prior to Obamacare, the government-run pooling approach was rolled out in more than 30 states, “but it wasn’t a satisfactory way of taking care of people” due to underfunding, Jost says.
‘Radical’ change to Medicare
Jost adds that Price’s proposal to transform Medicare into a voucher system would be a “radical” adjustment tantamount to privatizing a program that currently serves some 54 million people, the majority of whom are elderly and about nine million of whom are disabled.
Privatizing Medicare was something Trump said he would never do. He also said not long ago, after a meeting with President Barack Obama, that he would retain certain provisions of Obamacare.
“Trump may have said that, but everything with the Affordable Care Act is so intertwined,” says health economist Timothy McBride, who teaches at Washington University in St. Louis.
“[The law] was long for a reason. You can’t cherry-pick 12 things and do an à la carte legislation.”
McBride expects the Republicans will have to pass a new bill to replace Obamacare.
“Because they promised they would,” he says. “The question is what that bill’s going to look like.”