All leading Republicans who are committed to repealing all or key parts of the Affordable Care Act (ACA) also emphasize their commitment to maintaining the law’s most popular part: banning pre-existing condition exclusions and medical underwriting by preserving the ACA’s (also known as Obamacare) policy of “guaranteed issue.” But the fine print in Republican proposals betrays that commitment, including legislation filed on January 26 by House Energy and Commerce Committee Chairman Greg Walden (R-OR) threatening health security for tens of millions of Americans.
Medical underwriting is the insurance industry practice of issuing and pricing health insurance based on an individual’s current or prior medical condition. Insurers use medical underwriting and pre-existing condition exclusions to avoid covering anyone who might cost them money. The Walden bill, called the “Preexisting Conditions Protection and Continuous Coverage Incentive Act,” pretends to continue the ACA’s ban on medical underwriting, but would, in reality, do the opposite.What are pre-existing conditions that can prevent you from obtaining coverage?
[The Q&A below was published in Harvard media this past week.]
How might the election of Donald Trump as the next U.S. president impact public health over the next four years? John McDonough, professor of the practice of public health at Harvard Chan School, who worked in the Senate on the passage of the Affordable Care Act (ACA), offers his perspective in this Q&A.
John McDonough
Many are worried that Obamacare will be in deep trouble—and likely be repealed—once Donald Trump is in the White House, working with Republican majorities in both the House of Representatives and the Senate. A week after the election, Trump appears to be hedging on his prior pledge to completely do away with the health reform law. What do you think will happen to the ACA—and to the millions of people who gained health insurance because of it?
The likelihood for total 100% repeal of the ACA is unlikely for two reasons: One is that this would have to be accomplished through regular legislative order in the U.S. Senate and Republicans would not be able to attract the necessary eight votes needed from Democratic senators to do this. Of course, if Republicans choose to abolish the filibuster, that would change. A second reason that repeal is unlikely is that many Republicans appreciate many non-controversial provisions in the ACA and repealing them would be backward steps they would not want to make happen.
Instead, and for now at least, Republicans appear to be moving toward a two-track process of “repeal and replace.” Repeal of the ACA’s essential health insurance coverage provisions, as well as the new taxes that financed the ACA’s expansions, could be achieved through the special “budget reconciliation process,” which only requires 51 votes for passage and cannot be filibustered. This would take some months to achieve, and is doable as long as 50 of the 52 Republican senators are willing to vote to eliminate coverage for as many as 22 million Americans—the number newly insured under the ACA—and their willingness to do that is not yet certain. Republicans did vote to repeal the most important parts of Obamacare in January of this year, but they did it knowing that President Obama would veto the measure. It would be a different vote knowing that President Trump would sign it.
Replacing the ACA with some other sort of health care law would be far more difficult because that legislation would need to proceed through regular legislative order and could and would be filibustered by Democrats, thus blocking the legislation. So it is conceivable that repeal could happen and replace might not follow, which would leave the up-to-22 million most at risk in a most difficult situation.
It’s been reported in the media that President-elect Trump may consider keeping some of the ACA’s more popular provisions, such as the requirement that insurance companies not deny coverage to people with pre-existing medical conditions, or that children up to age 26 can be covered under a family’s health plan. How do you think this might play out?
House Speaker Paul Ryan and House Republican leaders, in their “Better Way” document on repeal and replace last summer, indicated that they would continue the ACA’s “guaranteed issue” provisions—those making it illegal for insurers to deny anyone coverage because of health status, age, gender, or other factors—though only for those who are able to maintain “continuous coverage” with no or only short-term coverage breaks. For the millions of Americans who find themselves unable to afford coverage for some period of time, Republicans would, by their own words, return pre-existing condition exclusions and medical underwriting—charging the sick higher prices than the healthy. The provision for children up to age 26 being able to stay on parent’s health insurance policies is most likely not to be repealed.
How might the new president’s policies impact women’s health? He has said he would nominate a conservative Supreme Court justice who would be in favor of a pro-life agenda. Could this lead to Roe v. Wade being overturned? What other ways might women’s health be impacted under the Trump administration?
Even with a Trump appointment to the U.S. Supreme Court, there are five current votes, including Justice Anthony Kennedy, opposed to a Roe v. Wade repeal. So President Trump would need at least one additional replacement of those five to have a chance at repeal.
Other aspects of women’s health coverage are at risk because of Republican plans to repeal large portions of the ACA. Republicans want to return all discretion over required benefits to states, including the ACA’s mandates on benefits such as birth control, mammography, prescription drugs, behavioral health, and much more. So it’s possible that women could lose coverage for services that are currently free, such as contraception, mammograms, folic acid supplements during pregnancy, and screenings for gestational diabetes, sexually transmitted diseases, and cervical cancer.
Trump broke with conservative orthodoxy when he said that he’s in favor of Medicare being able to negotiate drug prices. He also has said that he would take on the Big Pharma lobby in order to reduce high prescription drug costs. Do you think he’ll be able to follow through on these pledges?
President Trump’s administration would only be able to negotiate drug prices or make other significant changes in pharmaceutical policies with the consent of Congress, which is most unlikely to provide that authority to him. Also, though the health policy section on his campaign website included drug-related proposals, the health policy section on his presidential transition website includes no mentions of these.
There were a number of health-related ballot initiatives across the nation. Three states, including Massachusetts, voted to legalize recreational marijuana and another three voted in favor of medicinal pot; voters in California, Washington, and Nevada approved various gun control measures; Californians raised cigarette taxes; and four cities voted to tax sugar-sweetened beverages. Also, Colorado rejected the establishment of a single-payer health insurance system in that state. How are these ballot initiatives changing the public health landscape?
On recreational marijuana, the tide of public opinion is changing the national landscape in spite of bipartisan opposition to this liberalization from elected officials all over the nation. It feels somewhat like the fast-changing tide a few years ago on gay marriage. And it feels unstoppable.
Taxes on sugar-sweetened beverages, at least on the local level, seem to be approaching the level of public acceptance we have seen in prior years with relation to tobacco taxes. The public seems supportive, at least in cities, especially when the revenues raised are clearly defined in terms of spending targets, such as public education. We have yet to see this approach pushed at a state initiative level, which would be a much more challenging proposition.
Regarding the vote against single-payer health insurance in Colorado, it seems that the U.S. sees one of these single-payer ballot initiatives every decade or so, and in each case, they start with some robust public support and then lose in a landslide: California in 1994, 73% to 27% no; Oregon in 2002, 77% to 23% no, and now Colorado in 2016, 80% to 20% no. It has always been a difficult sell and the Colorado results demonstrate that it still is.
(This article was published on Friday, September 18 on the Health Affairs Blog. It was prepared by me and Max Fletcher, a Master of Public Health student at the Harvard TH Chan School of Public Health.)
A new spate of proposals from Republican presidential candidates to repeal and/or replace the Affordable Care Act (ACA) raises the important question: Given an unobstructed opportunity, what would Republicans really do with the Affordable Care Act? Would they repeal the law wholly or just in part? With what might they replace it?
Some suggest that Republican Congressional leaders only advance full repeal to placate their Party’s conservative base, knowing well that repeal cannot survive a certain veto while Barack Obama is President. In January 2017, that obstacle will vanish if Republicans control the White House and both branches of the U.S. Congress. What then?
Unfortunately, the proposals now being advanced by the Presidential candidates are far less than comprehensive, and leave many more issues unanswered than answered.
Though no ACA replacement plan has progressed in either branch (or in any standing committee) of Congress since the law’s 2010 signing, Republican office holders and conservative think tanks have advanced expansive proposals. We identified eight plans offered between 2012 and 2015 that address the ACA’s fate and propose substantive replacement. We examined each in detail to determine the extent of agreement on alternatives to the ACA. We created a chart comparing the eight proposals according to key policies. Table 1 below provides identifying information about the eight plans:
Of the eight proposals, four were advanced by Republican Members of Congress. The most prominent of these is the Patient CARE Act offered by Sens. Richard Burr (R-NC) and Orrin Hatch (R-UT) and Rep. Fred Upton (R-MI); the latter two are the current chairmen of the Senate Finance Committee and the House Committee on Energy and Commerce respectively, both committees with primary ACA jurisdiction. Though narrative versions of Burr-Hatch-Upton were released in 2014 and 2015, the authors have not translated their proposal into legislative language that can be evaluated by the Congressional Budget Office (CBO). While the other Congressional proposals have been introduced as legislation, none have received CBO scores. Continue reading “What Would Republicans Do Instead of the Affordable Care Act?”
Health Stew 