A splintering in the Republican party forced Speaker Paul Ryan to pull the American Health Care Act, aka Trumpcare, from a House of Representatives vote, and, at least for now, it has been put to bed. Ryan did not have the votes to repeal the Affordable Care Act and replace it with Trumpcare. But, beware, as Margot Sanger-Katz reports for the New York Times, the Trump administration and the Republican leadership could hurt Medicare, Medicaid and the ACA without ACA repeal.
The ACA requires Trump administration support and Congressional appropriations in order for its effective implementation. There is strong reason to believe that President Trump and Secretary of Health and Human Services, Tom Price, have every intention of doing what they can to destroy the ACA and reform Medicare and Medicaid through executive action. Indeed, they’ve already begun, with Trump declaring that “[The ACA] is exploding now,” when it is not.
Under the ACA, for example, the Department of Health and Human Services has the authority to change Medicare significantly through demonstration programs intended to bring down costs and improve patient outcomes. Secretary Price could use this power to reform Medicare in dramatic ways. Moreover, Secretary price can give more authority to the states with regard to Medicaid through the CMS Innovation Center. For example, he could give states waivers to impose premiums and cost-sharing requirements on Medicaid.
With regard to the state health insurance exchanges, President Trump has already directed the IRS not to enforce the ACA requirement that everyone either have insurance or pay a penalty for not having insurance. And, the IRS believes it has a way to do so without violating the ACA. If people don’t fill out the line on their tax return indicating whether they had insurance in 2016, the IRS plans not to reject the return. As a result, fewer young people will likely sign up for coverage, gambling that they will not need health care. With more older and less healthy people in the exchange, premiums and out-of-pocket costs for enrollees will rise, possibly putting the health plans in the exchange in a death spiral.
And, though insurance premiums are relatively steady in the state health insurance exchanges, insurers understandably are wary about their future. If Trump and Price show little or no support for the exchanges, it is to be expected that more insurers will pull out of the exchanges. They will need to decide by June 21 whether they will continue to offer insurance in the exchanges in 2018.
The Trump Administration is also not likely to oppose a House challenge to the deductible and copay subsidies the ACA provides to people with low incomes in the exchanges, as the Obama Administration did. More than half of enrollees in the exchanges rely on those subsidies. Without them, both enrollees and insurers will be hurt.
And Secretary Price may not be willing to use his muscle to ensure that the exchanges deliver robust coverage, which Obama administration officials did. Rather, he may support insurers who want to raise deductibles and restrict coverage, to the extent he has leeway to do so.
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