When the 45th president of the United States takes the oath of office on January 20, 2017, the Affordable Care Act will face its first test under a new commander-in-chief.
Democratic presidential nominee Hillary Clinton and Republican presidential nominee Donald Trump have very different approaches to the future of health care reform, with Clinton promising to “protect” the ACA, and Trump calling for a full repeal.
The truth for both sides is somewhere in between.
Whether the executive branch remains blue or turns red, the ACA will have had nearly seven years to mature since it was signed into law.
A full repeal is not realistic for many reasons — perhaps the most obvious being that several provisions are popular with both employers and the public and enjoy bipartisan support.
And while each candidate has a vision for the future of health care, the fate of that vision and of the ACA itself will depend heavily on the partisan makeup of Congress.
The ACA under Trump
While Trump's promise to repeal the ACA and replace it with “something terrific” is not realistic, replacing significant pieces is possible if Trump is elected and the House and Senate remain under Republican control. Trump's health care plan falls into three buckets:
More choice, lower costs, greater flexibility — Expand access to health spending accounts to inspire movement toward consumer-directed health plans (CDHPs). This also supports greater health insurance portability, which includes subsidies for purchase of health insurance, private exchange options, a repeal of the individual and employee mandates and a change to the definition of a full-time employee. A major point to consider is the tax treatment of employer-sponsored insurance. Currently, the value of benefits is excluded from income. Trump is calling for a cap on this exclusion as an alternative to the Cadillac Tax (which he says he’ll repeal). This also supports insurers operating across state lines and pooling for small businesses.
Protecting and strengthening coverage options for all Americans — Supports insurance market reform, including many provisions already established in the ACA, such as no pre-existing condition exclusions, allowing children on parents’ plan through age 26, no lifetime limitations on coverage, no rescissions, guaranteed renewability and continuing coverage protections. This supports additional state funding for high-risk pools and a one-time open enrollment, which, as long as consumers maintain continuous health insurance coverage throughout their lives, would prohibit an insurer from re-rating its plan based on medical condition.
Protecting Medicare and Medicaid for future generations — Advocates modernizing a premium support model for Medicare that would guarantee every enrollee an income-adjusted contribution toward a plan of their choice, with catastrophic protection. This also imposes no changes for persons 55 or older.
The ACA under Clinton
There are five key elements of Clinton's health care plan that support employer-sponsored insurance (ESI) and do not support a single-payer system, a solution her opponent in the primaries, Bernie Sanders, made a central part of his campaign.
Expand access — Proposes a government plan option for coverage on each state's public exchange, which would compete against commercial plans. Also wants to allow individuals to opt into Medicare at age 55 and expand primary care funding at federally qualified health centers from $20 million to $40 million.
“Protect” the ACA — Opposes any efforts to cut back or repeal the ACA. To offset rising premiums on the public exchange, suggests subsidy increases. Would work with governors in the 19 states who have not taken up ACA Medicaid expansion to change their minds.
Control health care costs — Believes that workers should share in the slower growth of national health care spending through lower premiums, deductibles and copays, but seeks to limit out-of-pocket costs for the insured and to enhance government authority to reject “excessive” premium increases.
Reduce prescription drug costs — Suggests limits on out-of-pocket costs for prescription drugs, specifically through government programs like the exchanges, Medicare and Medicaid.
Support “value” in health care — Supports initiatives to promote value-driven health care programs established by President Obama, including the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Center for Medicare & Medicaid Innovation (CMMI) and accountable care organizations (ACOs).
Uncertainty puts benefits communication at forefront
Potential revisions to the ACA, whether they are incremental or substantial, will require strategic, thoughtful benefits communications to prepare plan participants for the impact on their plans and, ultimately, on them and their families.
We already know from multiple studies and surveys that plan participants do not have a good grasp of how health insurance works and, in fact, don't think about their coverage until they actually have to use it. Anything brokers and their clients can do to provide context for potential plan design changes will go a long way toward increasing acceptance and understanding of those changes when the time comes.
Whether Clinton or Trump is elected, companies that employ or outsource knowledgeable benefits communication expertise will be better equipped to navigate changes to the ACA and have the best chance of engaging and retaining a productive workforce.
ESI future looks bright
With neither candidate proposing a viable replacement, the future of employer-based insurance is strong. The timeline for a transition to a single-payer system (or Trump's proposal of portable and non-employer binding coverage) is likely decades rather than years away, and employers will be reluctant to eliminate any program that will give them an edge in recruiting and retaining talent.
Congress and the current administration also see the value in ESI, a perspective which contributed to postponement of the Cadillac Tax to 2020. Clearly, the government does not want to push employers into decreasing or dropping coverage entirely.
That said, the ESI market will continue to evolve from both a product and service perspective in response to employer and employee needs and changing regulations.
Full repeal is not an option
The political and economic backlash from suddenly ending health care coverage for an estimated 20 million Americans would be too great for full repeal to truly be an option.
Insurers have invested millions of dollars in systems to support ACA environments and would incur additional costs to retool or replace what they’ve put in place.
Employers would face similar challenges, nullifying in-house and consulting investments to comply with new, revised or disbanded ACA provisions.
While many of Trump's provisions are similar to what is already included in the ACA, there are operational differences that rely on a principle of conservative governance.
As an example, while ACA subsidies increase as premiums increase, Trump's plan calls for subsidies to remain flat, encouraging competition as a way to drive down premiums and make insurance more affordable.
Promoting private exchange options in addition to the public exchange could, in the spirit of competition, bring down prices. Neither of those outcomes will occur, of course, unless changes are made that bring insurers back into the marketplace, after the exodus we’ve seen in past months.
A recurrence of the full-blown ACA debate of 2009-2010 is not realistic. Instead, new health care legislation will emerge in the context of incremental changes that might even contain some elements of bipartisanship.