Insurance agents, brokers and others are starting to wrap their brains around an amazing reality: Barring a very unlikely Electoral College upheaval, a Republican administration will be in charge of administering the Affordable Care Act.

The fourth-annual ACA open enrollment period for 2017 started Nov. 1 and is set to end Jan. 31, 11 days after Donald Trump is to be sworn in as the next president of the United States of America.

Barack Obama had to work hard to get anything big passed during his first term in the White House, even though he started with personal experience as a senator, a Democratic majority in the House and what was regarded as a "filibuster-proof" Democratic majority in the Senate. The most liberal Democrats gave him almost as much grief as the Republicans.

Trump appears to be on track to enter the White House in what could be a weaker starting position. He has no personal experience with serving in the federal government, and he will start with only a narrow Republican majority in the Senate.

To get ordinary legislation through the Senate, Trump will have to hold on to what are regarded as the most moderate Republican senators, Dean Heller of Nevada and Susan Collins of Maine, and at least seven of the Democratic senators who are at least as close to the neighborhood of the center as Sen. Charles Schumer (D-N.Y.), who is likely to be the next Senate minority leader. One of those moderately liberal senators Trump might need to court is Sen. Tim Kaine (D-Va.), Hillary Clinton's running mate.

Kaine lost, but he helped his ticket win in Virginia, on a difficult night for Democrats, and that might give him some extra clout in the Senate.

Meanwhile, Trump knows about insurance and benefits issues mainly through his role as a business owner, and through his interaction with campaign advisors, such as Dr. Ben Carson, a former Johns Hopkins neurosurgeon.

Trump has said he wants to repeal the ACA and replace it with a combination of an expanded health savings account program and interstate insurance sales.

Here are some ideas about how that could hurt some health insurance industry players and help others over the next two years:

Likely losers

1. The term "Affordable Care Act."

The incoming Trump administration may find actually killing ACA is time-consuming, or even impossible. Some major Republican ACA replacement plans have included many popular ACA provisions.

But the rapid growth of ACA jargon has confused even the friends of the ACA, and the new administration may be eager to rid itself of as much of that terminology as possible as quickly as possible.

2. The consultants and think tanks that shaped the ACA.

The ACA idea people might have been right about what they proposed. ACA defenders might say ACA World problems have had more to do with the rushed, secretive process Democrats used to get the ACA legislation through Congress, and with fierce Republican opposition to the law, than with the ideas inside the law.

But, in the end, the ACA legislation created a framework so complicated and market upheaval so severe that many Democrats, including Clinton and Kaine, avoided talking much about it on the campaign trail. The fourth open enrollment period became a topic to avoid, rather than a triumphant event to celebrate.

3. Bernie Sanders and other advocates of single-payer health care.

Some of Vermont Sen. Bernie Sanders' allies say Clinton was simply too corrupt, and too friendly to big corporations, and that conspirators inside the Democratic Party apparatus kept him off the general election ballot. But his supporters did get a government-run health care system proposal on the ballot in Colorado, a state that often votes for Democrats. In a way, the measure could be considered a stand-in for Sanders himself.

Clinton scraped up a narrow victory in Colorado, and Sen. Michael Bennet, a Democrat, beat off a challenge by Republican Darryl Glenn.

But Bennet and other prominent Democrats in Colorado opposed the measure, and Colorado voters defeated it by a margin of 20.3 percent to 79.7 percent.

4. Single-state Blue Cross and Blue Shield gorillas.

Some of the remaining Blues are giant, nonprofit companies that cover half or more of the commercial health plan enrollees in their markets.

Efforts by Trump to allow interstate sales of health coverage could appeal to some Democrats. State insurance regulators contend that letting insurers choose their own home-state regulator could lead to insurers having no real choice but to flock to the weakest regulator.

Interstate health coverage sales could also benefit the big national carriers at the expense of carriers that have not had to face serious competition in years.

5. Nonprofit ACA exchange plan helper programs.

The Trump administration may see grants for state ACA exchange navigator programs and certified application counselor programs as love notes to Democratic-supported health policy organizations.

Possible winners

1. Trump's own insurance and benefits advisors.

Trump may be someone who avoids reading long policy position papers or listening to long policy presentations. Instead, he may develop ideas about who to trust, and what to think about health policy, by talking to people he already trusts, or thinking about his own experiences as a benefits buyer.

That means that, in some cases, a brief Trump entity employee benefits update included in an ordinary employer newsletter five years ago, just to fill space, might have caught Trump's eye and have more influence over him than 200-page paper a centrist think tank rolls out next week.

Carson and Indiana Gov. Mike Pence, his vice president-elect, could be two major sources of health policy advice or about where to get advice, and his own company's top-level benefits managers might be other sources.

For his payroll company based in Fifth Avenue in New York City, for example, the names of Jeffrey McConney, the Trump Organization controller, and Ronald Lieberman, the company's executive vice president for management and development, appear on benefit plan Form 5500 filings for 2015.

2. HSA Bank and other HSA providers.

In the past, both Democratic and Republican budget economists have wondered whether health savings account tax breaks and similar tax breaks do enough to help struggling people to justify their cost to the Treasury.

But Carson and many other Republican ACA replacement drafters have included expanded health savings account program proposals in their proposals, and Trump has briefly mentioned health savings accounts during many campaign stops.

That could be good news for major health savings account services providers, such as Sheboygan, Wisconsin-based HSA Bank and the health savings account banking unit at Minnetonka, Minnesota-based UnitedHealth Group.

3. CNO Financial, Genworth Financial and other private long-term care insurers.

One reason private long-term care insurance is struggling is because of bad product design, pricing and underwriting decisions that were made long ago.

A second reason is court-imposed changes in how long-term care insurance issuers pay out benefits.

A third reason is low interest rates.

But a fourth reason is that many of the types of policymakers that have advised the Obama administration hate long-term care insurance issuers because of past wars over a proposed Medicare long-term care benefits program and over an ACA provision that was supposed to create a universal voluntary long-term care benefits program.

Those health policy shapers will no longer have much clout in Washington.

Another reason long-term care insurance issuers could benefit is that the Trump payroll service has offered a group long-term care insurance program.

Pence, the vice president-elect, is the governor of CNO Financial's home state, and has helped promote his state's Long Term Care Partnership program, which uses Medicaid-related incentives to encourage people to buy private long-term care insurance.

Meanwhile, Kaine, the former vice presidential candidate and potential Senate vote Trump now needs to get ordinary bills to the Senate floor, has been governor of Virginia, which is the home state of Richmond, Virginia-based Genworth Financial. Kaine has also helped start his own state's Long Term Care Partnership program.

If anyone could put in a good word for private long-term care insurance, it might be Pence and Kaine.

4. Anthem.

Indianapolis-based Anthem has been warm to the ACA public exchange system, but it's also based in Pence's home state. It might have an opportunity to be on good terms with the Trump administration's secretary of Health and Human Services.

5. Consumer Operated and Oriented Plan carriers and carriers waiting for payments from troubled ACA risk programs.

Trump administration officials could simply tell the CO-OP managers and ACA risk program creditors, "You're fired, bozos," but one way the Trump administration might be able to move a major ACA changer or replacement bill through the Senate would be to help insurers and other coverage issuers that are facing severe financial problems simply because they believed the Obama administration when officials said ACA risk corridors program and ACA risk-adjustment program money would be coming soon.

In September, the Republican staff of a House committee put out a CO-OP report in which the staffers wrote sympathetically about how the CO-OPs appeared to be the victims of Obama administration officials' incorrect statements about how ACA programs would operate.

The Trump administration may have an easier time getting bipartisan support for legislation to fix the ACA risk program than a Democratic administration would, and Trump, who has been through bankruptcy reorganizations and faced infuriating government policy changes himself, could see remedying the risk program problems as more fair to the carriers and better for minimizing the federal government's total ACA risk program-related failure costs.

Instant Insights /

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