The uncertainty of death and taxes

On Nov. 1, enrollment in state health insurance exchanges opened across the country. The exchanges are one of the most visible elements of the Affordable Care Act (also known as Obamacare), a sprawling law that ultimately reached 2,700 pages of print before its passage. Just seven days later, Donald Trump was elected president, with a promise to “completely repeal Obamacare.”

Since the election, I’ve been trying to make sense of what will happen next. By that I don’t just mean emotionally process what’s going to happen, I mean literally figure out what is going to happen to the health system over the next four years. It’s been harder than I expected—mixed messages and a lack of information from the Trump transition team result in uncertainty about what the future will bring.

The Trump campaign website has a sparse 1,090 word statement detailing their position on health care policy. It contains mostly standard conservative boilerplate of health savings accounts, increased cost transparency, and loosening of insurance regulations. It states that the ACA will be completely repealed, but does not detail what it will be replaced with. The Rand Corporation conducted an analysis of the policies explicitly outlined in Trump’s platform. It was estimated that Trump’s proposal would decrease the number of insured by 20.3 million and increased the federal deficit by $5.8 billion, by eliminating ACA provisions that reduce spending (such as changes to Medicare payments) and generate revenue (such as taxes on devices). The Trump transition website devotes just 309 words to healthcare, with the language no more illuminating or instructive than the campaign website.

When considering Obamacare repeal, it’s important to remember that the ACA deals with much more than just insurance. The law provides subsidies for the purchase of individual insurance, prevents insurers from denying coverage due to a pre-existing condition, allows children to remain on their parents insurance until age 26 and mandates that all citizens have health insurance coverage or pay a fine. However, other provisions move Medicare away from a fee-for-service payments, affect the way hospitals receive funding for indigent care and even created a non-profit institute to conduct research on the clinical effectiveness of medical treatments. The law contains many provisions that were path of the discussion on the campaign trail. However if the ACA is repealed, all provisions, not just the ones that make good talking points, would go with it.

Yet in the days since the election, there are significant reasons to question whether Trump actually intends to carry out the policies he explicitly stated in his platform. In an interview with the Wall Street Journal, Trump backed off his strict repeal rhetoric stating “either Obamacare will be amended, or repealed and replaced.” In an post-election interview with “60 Minutes,” Trump stated that replacement and repeal of the ACA would be “simultaneous.” This is concerning since his platform states that “we will ask Congress to immediately deliver a full repeal of Obamacare,” but 62 days out from inauguration, no comprehensive replacement plan has been released.

The past words of the President-elect only further confuse those anticipating the future. In September, 2015, during an interview with “60 Minutes,” the President-elect stated that he was “going to take care of everybody.” As for the uninsured, Trump stated “I would make a deal with existing hospitals to take care of people…the government’s going to pay for it.” In an MSNBC town hall this February, Trump stated, “we can't let people die in the streets… We're going to take care of them. We're going to take care of them. We have to take care of them.” Over the years, the President-elect has stated his personal support of universal healthcare on several occasions.

However, a cadre of deeply conservative advisors, staff and colleagues now surrounds Trump. This June, after years of symbolically voting for the repeal of Obamacare, House Speaker Paul Ryan proposed an outline of a healthcare plan that could replace it. Like Trump’s platform, Ryan’s plan is light on details but primarily involves replacing the ACA with tax credits, rolling back federal funding on Medicaid for poor patients, changing Medicare to a fixed subsidy for private insurance and removing protections for those with pre-existing medical conditions. Many speculate that a Trump replacement could mirror this legislation.

The ACA is not without its flaws, nor is Trump’s platform without its merits. As reform legislation, the ACA primarily focused on expanding access through subsidization. Provisions addressing cost of care and quality of care were present, but not central. Trump’s platform proposes improved cost transparency for medical services and importing low cost medications, both provisions that could increase competition in the health sector. Nevertheless, the irrefutable fact is that 20 million people have health insurance coverage because of the ACA. As for open enrollment, despite increases in the cost of premiums and the looming political uncertainty, over 1 million Americans have selected plans on the exchange since November, with nearly 250,000 new consumers entering the exchange this year.