How the GOP could try to repeal or change the ACA
After six unrelenting years of a GOP-led war against the Affordable Care Act (ACA), President-elect Donald Trump (R) and the Republican-led House and Senate will finally have the chance to repeal or rollback the healthcare law.
Majority Leader Mitch McConnell on Wednesday hinted the Senate could act quickly on moving forward with its ACA agenda. "It's pretty high on our agenda as you know," McConnell was quoted in Politico. "I would be shocked if we didn't move forward and keep our commitment to the American people."
There are multiple possible paths to that end, though questions remain as to what exactly Trump and his anti-ACA supporters will do now that they have the chance, which was previously viewed as a longshot. Will they really sweep health insurance out from under the feet of more than 20 million people who have become insured under provisions of the law? Will they roll back other aspects of healthcare reform that have been widely well received, or opt rather to take apart the health law in a piecemeal fashion to salvage some portions?
As noted by STAT, some ACA provisions are loathed, such as the mandate to buy health insurance or pay a fine, while others have been embraced, like keeping kids on insurance until age 26 and ending discrimination against those with pre-existing health conditions.
The path to repeal
Come January when Trump takes office, he would have to get a 60-vote supermajority in the Senate to actually repeal the Affordable Care Act in its entirety. However, Republicans have too slim a majority to reach that vote without some bipartisan cooperation.
Another route to dismantling the ACA is available. Republicans already showed last year they could potentially take down the ACA by using the reconciliation process to block the spending that supports it, as Senate rules only require a simple majority to pass reconciliation bills. Though Obama vetoed that bill, HR 3762, that plan could now serve as a blueprint to change the law. The question is whether so many Republicans would support such a bill when the stakes are for real and its not just a gesture of principle.
As noted by Vox, that plan included a two-year transition period to allow time for policymakers to figure out what to implement in place of the ACA, which would presumably be the case if attempted again to avoid a sudden and unpopular disruption.
On the downside, while a piecemeal approach could maintain some positive aspects of healthcare reform, it could also have the potential to throw the system into further disarray than a wholesale repeal, suggested the New York Times, considering that so many of the law's provisions are interdependent.
If nothing else, simply undermining the law and failing to enforce it or promote it, without even having to change it, could unravel the ACA, suggested a new Health Affairs blog by Timothy Jost. Changes in leadership and abandonment of current initiatives could bring an "implementation vacuum," he argued, and changes in handling of legal cases around the ACA and payments to insurers could be sufficient to implode the program.
Reactions from the healthcare industry
Amid the uncertainty, numerous organizations took forward-looking stances Wednesday that suggested advancements toward value-based care may be here to stay, ACA or no ACA.
Healthcare provider alliance Premier noted it hopes to see the industry build on reforms such as MACRA and supporting alternative payment models by eliminating antiquated regulations that discourage innovation and accountability. "We believe that accountable healthcare providers, working with consumers in their communities, can propel our system to be the world leader by all measures," the company stated.
Trade association AMGA also voiced support for the continued transition to value-based payment. "Every administration brings change, and I am confident that multispecialty medical groups and integrated delivery systems will play a key role in shaping the future of health care in the country, stated AMGA’s President and CEO of Dr. Donald W. Fisher.
According to Fitch Ratings, the impact of Trump's policies can't be predicted at this time given they have been insufficiently articulated. However, "Successful efforts to repeal or materially replace the ACA would be a credit negative for healthcare providers as it is contributing to higher volumes of insured patients," it noted. It added this would also be "modestly negative" for the pharmaceutical industry because fewer patients would have prescription coverage, but that at the same time, drug companies are likelier to see "fewer headwinds" than they would have under a Clinton presidency.
All in all, even with the many questions that remain, "the fundamental outlook for the U.S. corporate healthcare industry remains positive despite the election outcome," Fitch stated, suggesting demand can be expected to grow organically through demographic shifts and emerging markets. "A repeal of the ACA may slow the nascent evolution toward value-based reimbursement schemes, but Fitch believes the shift toward linking pricing to patient outcomes will continue as patients and health insurers grapple with the growing burden of healthcare costs over the longer term."