The way Ron Levy sees it, American health care is a delicate ecosystem that will soon be undergoing enormous challenges due to the potential repeal and replacement of the Affordable Care Act (ACA). The ACA expanded and reformed insurance coverage to serve more than 20 million individuals, small business employees, and people living in poverty.
Like any ecosystem, when you change one thing, it impacts everything else. “There’s connective tissue running through it all,” says Levy, who works as Saint Louis University’s health management and policy executive-in-residence to help students and colleagues understand the changes coming to health care.
With at least two years ahead of Republican rule in Washington, Trump’s movement to “repeal and replace” the ACA is raising both concern and support among Americans in need of health coverage. Some fear losing their plans, while others are in favor of creating a more competitive health care market that could slash coverage costs.
St. Louis Magazine asked Levy and Timothy D. McBride, Professor at Washington University’s Brown School, to weigh in on what changes to the ACA might mean for you.
SLM: What is Trump’s administration proposing with its “repeal and replace” agenda?
Levy: It appears [the Republicans in Congress and the President-Elect] want to repeal or eliminate a number of the ACA provisions, including: individual mandates and employer requirements; Medicaid expansion (12 million newly covered) with possible “block grants" to the states; health insurance subsidies for individuals and small business employees in the Health Insurance Exchanges (8 million newly covered) with tax credits; and many of the revenue streams the ACA used to expand coverage, as well as removing insurance barriers to coverage such as pre-existing conditions.
New provisions being proposed include: removing state regulatory control of insurance companies and allowing the sale of insurance plans across state lines, as well as expanding tax credits to enhance health savings accounts. There is also the desire to maintain the insurance reforms regarding pre-existing conditions and allowing children up to age 26 to remain on their parents’ plans.
SLM: If the ACA is repealed, what options will be left for the 20 million people who could lose their insurance—especially those who are working and middle class?
McBride: [Those 20 million people] would lose these plans and coverage, and in most cases would be left uninsured. The cost of health insurance is prohibitively expensive for the vast majority of people who gained coverage. For example, all those brought in under Medicaid coverage are very low income—with less than 138 percent of the federal poverty line. We typically assume (based on empirical evidence) that if people need to spend over 10 percent of income on health insurance, they usually decide they cannot afford it.
SLM: The ACA struggled to attract the "young and invincible.” What strategy might Trump take to reach young, healthy, and higher income people?
McBride: If the ACA is repealed, it is hard to think of what would help people sign up who are young and “invincible.” This is because younger people tend to have lower incomes, and thus would be less likely to be able to afford coverage. The Trump plan includes some tax deductions to help people. However, this is unlikely to be much help to people who do not pay income taxes anyway.
SLM: What potential changes should women be aware of regarding their sexual health and reproductive rights?
McBride: This is an important issue. If it’s possible that coverage could be repealed this quickly, then these women should be concerned. However, it is important to know that even if the provision to provide free or reduced price contraception is repealed, it may take months (if not years) to repeal it, and, from what I have read, the Congress is suggesting they would make the repeal effect in 2018 or some later year like that.
SLM: Last thoughts?
Levy: What’s being proposed for replacement of the ACA puts a great deal of faith and reliance in the health care marketplace and competition ...The real question for “repeal and replace” is, will it deliver on its promises? Will [it] provide continued coverage for the 20 million newly insured Americans?
Want to get in on the conversation? Comment below.
