Even if Trump loses, Republicans still targeting ACA repeal

Regardless of whether Hillary Clinton or Donald Trump emerge victorious on Election Day, Republicans will continue their quest to repeal the Affordable Care Act.

Nevertheless, it’s unlikely, doctors will see much change in the number of insured patients they treat, even if Republican nominee Trump wins the presidency and his party retains control of Congress, healthcare watchers on Capitol Hill say.

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Repeal would take insurance away from millions of people, something even diehard anti-ACA Republicans realize could be a major political liability. So, rather than a repeal, watch for Republican efforts to make changes to the ACA that could have a long-term impact on how many patients are insured, such as eliminating the mandates requiring health insurance and the penalties for noncompliance.  

If Democrat Clinton wins the presidential race, such changes would prove difficult to pass, especially if Democrats capture control of the Senate, as well, notes Joe Antos, Ph.D., a health policy expert at the American Enterprise Institute. Clinton would more likely search for administrative ways to address such ACA issues as insurers dropping out of federal and state insurance marketplaces, he says.

However, a Clinton administration might be willing to work with Republicans to look at doctor payment levels under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), says Antos.

“The medical establishment awoke from its slumber and realized this [MACRA] is not a good deal for them,” says Antos. “I think MACRA provisions will be delayed under any president,” he says. “The idea of alternative payment models as a theory is great; how do you do it is always an issue.”

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If the Centers for Medicare & Medicaid Services issues any guidelines that indicate lower payment levels, the new Congress could be compelled to act, Antos predicts.

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Two bills introduced this summer demonstrate what Republicans may attempt in the next Congress. Sen. Bill Cassidy, MD, (R-Louisiana) cosponsored the World’s Greatest Healthcare Plan bill, saying “it strengthens the patient-physician relationship.” The bill, cosponsored with Rep. Pete Sessions, (R-Texas), does not call for repeal of the ACA.

Next: The ACA repeal dilemma

Rather, it gives individuals a $2,500 tax credit to use for the health insurance of their choice. Individuals could keep plans they’ve already bought on ACA exchanges or opt for other ones. The tax credit also can go into a health savings account that can be used to pay for unreimbursed medical expenses.

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Sen. John McCain (R-Arizona) in September introduced a bill that seeks to eliminate individual penalties for not having health insurance for people living in areas where only one insurer is available through the federal Healthcare.gov marketplace.

The Cassidy bill goes further, doing away with both the individual and employer mandates for having health insurance.

That provision in Cassidy’s bill raised eyebrows at the American Academy of Family Physicians, notes Robert Wergin, MD, board chair of the academy. “Our academy stance is healthcare access for all, and this [the Cassidy bill] might be a step away from that,” Wergin says. The AAFP has not taken an official stance on the bill, he adds.

Cassidy responds that if his measure is properly implemented, the number of individuals covered by health insurance would increase rather than decrease. His bill includes a provision for states to enroll people automatically in health coverage plans unless they opt out.

The ACA repeal dilemma

Speaker of the House Paul Ryan (R-Wisconsin) in June introduced a Republican blueprint that would go beyond Cassidy’s bill by repealing the ACA. Among the key points of Ryan’s plan are raising the Medicare eligibility age from 65 to 67, capping the tax deductibility of employer-based health insurance plans, expanding the use of health savings accounts and turning Medicaid into a state block grant program-all moves Republicans have championed in the past.

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Republicans deemed Ryan’s plan “a blueprint” because it lacked many specifics and was not introduced in the form of a bill in either House of Congress.

But Timothy Jost, JD, an emeritus professor at the Washington and Lee University School of Law and a proponent of the ACA says, “You can’t get rid of the ACA. That’s like saying ‘I’m going to get rid of the interstate highway system.’ But you could repeal or amend a lot of its important provisions. I doubt they will take insurance away from 20 million people even if many of those people don’t vote Republican.”