How will President Trump approach the ACA?

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With his unexpected win, President-elect Donald Trump will have to accomplish something he did not do on the campaign trail: offer a detailed plan to replace the Affordable Care Act for the nation’s uninsured.

After attacking Obamacare as a failure in debates and at campaign rallies, Trump could either eliminate the plan that has added roughly 20 million Americans to the insurance rolls — or amend it. Although Trump has touted a single-payer plan a few times early in his campaign, his website lists a healthcare vision that includes repealing and replacing Obamacare with Health Savings Accounts, creating a healthcare system that “promotes choice, quality and affordability” that will allow people to purchase coverage across stateliness to create “a dynamic market.”�

While the billionaire-turned-politician offered no details while campaigning on how he would cover the nation’s insured, insurance brokers and policy experts point out that there are areas on which leaders from both parties can agree. In fact, several insurance brokers called for a dismantling of much of the ACA.

Troy Underwood, the former CEO of BenefitsCONNECT, did not mince words: “I believe Congress should end it, but that's not likely.”

Paul Hughes-Cromwick, the co-director of the Center for Sustainable Health Spending at the Altarum Institute, declined to predict what a Trump health plan would look like so soon after the election. It is “utterly unpredictable as for all policy space in a Trump administration,” he says.

Others see an opportunity to fine tune the ACA and incorporate ideas from the GOP.

“The Republican response has to look as different from the ACA as it can, even though some portions were once Republican ideas, like the individual mandate,” says Edward Fensholt, senior vice president, director, compliance services of Lockton Companies.

The ACA isn’t working well, says Joel White, president of the Council for Affordable Health Coverage. “This bad situation is actually an opportunity to enact reforms that make markets workable. Affordability — holding health costs to wage or economic growth — wasn’t addressed meaningfully in Obamacare. Congress should take steps to do so now,” White says.

“We’ve never advocated repeal, because going back to the status quo of six years ago would be unacceptable to most. Every reform plan in Congress keeps some elements of Obamacare, such as allowing adult children to stay on a parent’s plan until age 26. So this is less about ending and more about laying out a vision and plan for how markets should work,” says White.

Alan Schulman, relationship manager for The Meltzer Group and a lobbyist for ACA reform, is in the “amend it” camp.

“It has some good features to it, however, it was called the Patient Protection and Affordable Care Act, there is nothing affordable about it,” says Schulman, citing his own health insurance bill. “My January renewal for my health insurance that covers myself, my wife and daughter in graduate school will increase to $ 1,931.00 a month effective Jan. 1, 2017. The plan has a $2,000 deductible. This is simply not affordable healthcare.”

Lockton’s Fensholt agrees, adding, “It’s a bill that has some lofty aims and has done some good things, but it comes as a tremendous price, complexity and hassle particularly for employers.”

So how to fix it?

“A key goal should be to bring more healthy people into the insurance exchanges. To make coverage more affordable for the young and healthy enrollees, the premium ‘rating band,’ now limited to 3:1 could be loosened to, e.g., 5:1,” says Hughes-Cromwick.

Hughes-Cromwick adds: “A second technical issue, the ‘family glitch’ — barring some employees who want insurance for their families from accessing the health insurance exchanges and receiving subsidies to make coverage affordable — should be remedied. Further methods to reduce cost-sharing for low-income exchange enrollees should also be considered.”

If Schulman were to advise the new president or Congress, he suggests reigning in the insurance and prescription drug companies’ profits.

“People must have skin in the game. [If they] practice good health [they get] lower rates, unhealthy lifestyles [get] higher rates,” he says, adding, “however, a large part of our population have chronic illnesses that are hereditary and passed down from one generation to another, and you have to accommodate those people.”

Underwood agrees. “Emphasize much better personal health. We spend too much on healthcare because we eat poorly and don't work out,” he says.

What aspects of the ACA should be broadened or eliminated? Shulman believes that despite that fact that all of the governmental exchanges and infrastructure cost “trillions of dollars, not one cent of that went to controlling premiums.” He adds, “The delivery system that was already in place was working fine. People could purchase insurance online from a carrier’s website or use a broker. Premiums are the same amount in and out of the exchange, why not consult with a professional?”

According to White, as a first step, Congress should lower medical costs. “The requirement that plans pay 80-85% of premium dollars in medical costs puts a bull’s eye on what is driving many premium increases. Congress should encourage less waste and greater safety in bloated hospital payments and other medical services,” he says.

Further, White believes that Congress must “implement prospective verification and streamline the use of special enrollment periods, which were supposed to be for life-changing events or special circumstances, but have been used to game the system and worsen risk pools in many instances.” He adds that lawmakers need to reduce the grace period for non-payment of premiums, repeal the ACA’s 3:1 age rating provision to lower premium costs for younger adults, and allow consumers to take their subsidies off the exchange to buy plans.

“This will foster plan competition to drive down costs,” according to White.

Subsidies in the exchanges should be “made more generous” and special enrollment periods and mandate exemptions should be scaled-back to promote a healthier risk pool, advises Hughes-Cromwick.

“While extremely unpopular, the so-called Cadillac tax should not be repealed as it promotes salutary incentives regarding excessive insurance coverage and hence high premiums,” says Hughes-Cromwick.

No matter what details are in the Trump administration healthcare plan, some elements of the current ACA will be as a good as gone.

“I think that [the] Cadillac tax goes away. Maybe even in the lame duck session it goes away. I think that’s about it,” says Fensholt.

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