No plan to replace Affordable Care Act has emerged in US Congress

Before his inauguration, President Donald Trump said Congress would vote to repeal the Affordable Care Act during his first week in office.

But nearly a month later, there has been little congressional action to fulfill this promise.

The lack of a clear plan from Republicans in Congress has left considerable uncertainty, according to health care experts in North Carolina — a state with high ACA enrollment.

“Honestly, I don’t know if there is a plan,” said Dr. Cedric Bright, an assistant dean of admissions and special programs at the UNC School of Medicine. “There’s the sentiment that they want to do it, but the question is, is there a plan formulated to do it?”

Some key provisions are likely to be cut

Brendan Riley, a policy analyst for the Health Advocacy Project at the N.C. Justice Center, said the beginnings of a repeal plan could be modeled after a 2015 budget reconciliation bill.

The bill, which was vetoed by then-President Barack Obama, would have eliminated Medicaid expansion, repealed tax subsidies that make care more affordable and done away with the individual mandate, which imposes penalties for qualified adults without health insurance.

Eliminating the mandate would cause the markets to collapse, Riley said.

“That’s the sort of thing that results in a death spiral in the individual insurance market,” he said.

Cynthia Cox, the associate director for the Program for the Study of Health Reform and Private Insurance at the Kaiser Family Foundation, said repealing the Medicaid expansion would affect low-income people the most.

“This would mean that low-income people, poor people, would have to either purchase their insurance on a private marketplace or go uninsured,” she said.

Over half a million people use the ACA marketplaces to buy insurance in the state, and 90 percent of them benefit from tax subsidies at risk of being cut, Riley said.

Cox said a full repeal of the ACA is less likely, as it would require support from congressional Democrats. But she said a full repeal would jeopardize patient protections for pre-existing conditions, limits on out-of-pocket costs, and access to preventive health and women’s services — provisions that affect everyone, not just people with ACA plans.

Any repeal plan would have a significant impact on UNC Hospitals, which receive funding from the federal government, Bright said.

No clear replacement plan in sight

Many congressional Republicans are balking at repealing the ACA without a replacement — but passing legislation to repeal the act would require a filibuster-proof Senate majority, which the party doesn’t have, Riley said.

“There is no consensus whatsoever within the Republican Party in Congress about how they want to replace the law and what they would replace it with,” Riley said.

Julie Henry, a spokesperson for the N.C. Hospitals Association, said Congress should take its time repealing the ACA.

“(A) concern of ours is that whatever happens, it will happen at a realistic pace so that we don’t rush to repeal without having a replacement plan in place,” she said.

Henry said the most important thing is for people to retain their coverage.

“From our perspective, the more people who are insured, the better,” she said.

But Cox said any replacement plan would have a transition period — which could result in premium hikes and coverage losses.

“Even if they did pass a replacement, even if they did get enough Democrats to vote on their replacement plan, it would take years to implement,” she said.

Uncertainty, nostalgia

Riley said insurers will react to the uncertain status of the ACA by leaving the marketplace altogether.

Humana announced Wednesday it would leave the ACA marketplaces in 2018 — the first major insurer to completely pull out.

Riley said the insurance industry doesn’t deal with uncertainty well.

“If they don’t know what kind of regulations and laws are governing the policies they have to sell and plan for next year, many of them may leave the market.”

For the first time since 2010, the ACA has a positive net approval rating, according to an NBC News/Wall Street Journal poll released in January. More people said the law is a good idea than at any period in its more than six-year history.

Bright said the law’s newfound popularity has caused Trump to soften his stance. He’s now saying he will preserve some of the law’s provisions.

“Folks are saying, ‘I know I voted for you because you said you were going to repeal Obamacare but I didn’t know that was going to impact me and my ability to be insured,’” he said. “‘So now I’m changing my tune — I heard what you said, but I didn’t know it was going to impact me.’”

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