The last six and a half years have been uncharted territory in our nation’s century-long debate over health reform. For the first time the fight was about how to implement an attempt at near-universal coverage rather over what this plan should look like and what could win enough support in Congress. The Affordable Care Act (ACA) has survived major political, legislative, and legal tests, including dozens of repeal votes, two Supreme Court decisions, the 2012 presidential election, and state-level resistance.
I was outside the Supreme Court on June 25, 2015 when the King v. Burwell decision was released. I was there the moment activists switched their signs from saying “Don’t you dare take my care” to “The ACA is here to stay.” I wrote that we could finally say with some certainty that they were right, the law is here to stay. They were wrong. I was wrong.
Donald Trump’s victory throws the future of health reform into complete chaos. He will take office in January 2017 with Republican majorities in the House and Senate. President Trump, Speaker Ryan, and Senate Majority Leader McConnell have all made repeated promises to get rid of Obamacare. They will face enormous pressure to follow through with their threats of repeal. Approximately 21 million people are projected to lose insurance if they follow through with their initial proposals.
The first step to figuring out where to go from here is understanding what decisions are on the horizon. Here are my first 20 questions about health reform under the Trump administration , in no particular order:
1. Will Republicans follow through with repealing the ACA? It is one thing to make threats when there is no chance they will come to pass. Where will health reform fit in the constellation of issues President Trump promised to focus on such as immigration and the economy?
2. If they decide to move forward with repeal in the first year—as I fully expect them to do—what will this look like? The details matter greatly. Will this be a mostly symbolic gesture to appease the conservative base without upsetting interest groups and taking away people’s insurance, or will this be a more comprehensive overhaul of the ACA?
3. Will legislation to repeal the ACA include specifics about what to replace it with or will these be two separate conversations? The history of health reform clearly shows that it is very hard to gain consensus on the details even if there is agreement on the broad goals. It will be much harder to pass repeal legislation if Republicans have to agree on what comes next.
4. I expect they will target the individual mandate. What will they do to combat the likely adverse selection problems that will lead to weakened risk pools and increased premiums increases?
5. Will they try to keep popular parts of the law such as allowing children to stay on their parents’ plans until age 26 or banning insurance companies from excluding people because of pre-existing conditions?
6. Will Republicans re-claim ownership of policy ideas they supported before they became part of Obamacare, such as using tax-credits to subsidize the purchase of private insurance through state-based health insurance exchanges?
7. Would they repeal the ACA’s coverage expansions across the board or use a federalism approach similar to the ACA which gives states flexibility to opt-in to keeping things like the Medicaid expansion and insurance exchanges?
8. What does a repeal timeline look like? How long will insurance companies, states, and consumers have to adapt before the coverage expansions are phased out?
9. What effect will all this uncertainty have on the current enrollment period for the exchanges?
10. What will state leaders do? In particular, what will leaders do in the states that have expanded Medicaid but voted for Trump, including Arizona, Michigan, and Pennsylvania? Will they fight to keep the federal money coming into their state or will they support ending the expansion?
11. Will we finally see a voter feedback effect in which the 20 million people who stand to lose insurance mobilize and fight against the ACA’s repeal? We have not seen this in Kentucky where Governor Bevin has undone the state’s exchange and is trying to remove or scale back the state’s Medicaid expansion.
12. What happens to all the current and future negotiations over Medicaid 1115 waivers? Will the Trump administration halt conversations? Will they be more permissive and allow things like work requirements which the Obama administration has rejected?
13. Will any state try a 1332 waiver? If so, how will the Trump administration respond?
14. Assuming block grants are part of the ACA replacement plan, what does this actually look like? What will this mean for states and beneficiaries?
15. This a crucial stage in the dramatic movement away from fee for service to alternative payment models. Will the Trump administration continue in this direction or shift course entirely?
16. What is the future of Accountable Care Organizations?
17. What happens when the Children’s Health Insurance Program (CHIP) expires on September 1, 2017? Will the bipartisan coalition that has supported CHIP further erode? Check out these articles in NEJM and Health Affairs that Jon Oberlander and I wrote about CHIP politics as it stood earlier this year.
18. Will Donald Trump follow through with his early campaign promises to allow Medicare to negotiate pharmaceutical prices?
19. Will public health emerge as a health reform issue that can transcend the partisan divide? In other words, will leaders be able to move beyond the fights over insurance coverage to focus on non-partisan population health issues such as maternal and infant mortality?
20. What does the future look like for federal funding for research on health services, medical care, and social sciences through AHRQ, NIH, and NSF?