Come January, the nation will have a president and Congress that have pledged repeatedly to repeal Obamacare. But in the meantime, there’s a sign-up period going on for people to buy coverage through the insurance exchanges created by the health law. So what happens now?
Connecticut officials say that, for the time being, nothing changes: People considering getting their coverage through the state’s exchange, Access Health CT, should continue to do so. Gov. Dannel P. Malloy noted Wednesday that Donald J. Trump won’t become president until Jan. 20, and that it’s unlikely the new Congress will have a full legislative package to replace the law at the start of its new term. (The deadline to sign up for coverage that begins Jan. 1 is Dec. 15; the open enrollment period runs through Jan. 31.)
But Access Health CEO Jim Wadleigh thinks some confusion is likely.
“We are trying to make sure that our customers understand that the Affordable Care Act is still the law and they have to enroll during open enrollment,” he said. “I’m sure they will think that now that there’s a new president, they don’t have to, and our goal is to make sure they understand we’re here to help them enroll.”
And Robert Laszewski, a Washington-based health policy consultant, expects the uncertainty over Obamacare’s future to have a significant and negative impact on the exchanges nationwide.
The scenario he envisions: Potential customers will think Obamacare is on the way out and that Republicans are bringing something new and better. Healthy people facing hefty premiums and deductibles will opt against buying insurance and wait for the replacement, while sick people will stick with the exchanges to have coverage.
“That means the risk pool that insurance companies are already losing money on will deteriorate further,” Laszewski said.
While people considering buying exchange coverage might be concerned about affording insurance in the future, Cynthia Cox, associate director for the Program for the Study of Health Reform and Private Insurance, said they should make decisions based on the current law. She noted that subsidies to buy coverage remain available and exchanges are still operating.
“Though there could be changes in the future, I think it’s unlikely that everything will be overturned overnight without some sort of replacement plan in effect,” Cox said. “At this point the Affordable Care Act has become the status quo, and 20 million people depend on it for health insurance, so making a change to that is going to require some thought and some time to come up with a replacement for it.”
Thousands of Connecticut residents get their health care coverage through programs created by the federal health law. As of October, Connecticut’s Medicaid program covered 204,689 poor adults without minor children, the group made eligible under Obamacare. Another 99,038 people had private insurance purchased through Access Health, 77 percent of whom received federal tax credits to discount the price of their coverage.
Far more are affected by provisions of the law that regulate the insurance market, such as requirements that preventive care be covered at no cost to patients, the prohibition on limiting the dollar value of the coverage a person can receive, and the requirement that insurers sell coverage to people regardless of their medical history.
Wadleigh said officials need to figure out how to move forward despite the uncertainty about the law’s future.
“Our staff is stressed. Our customers are stressed,” he said, adding that it is his job and that of other exchange leaders to “bring that calming voice to everybody.”
Lt. Gov. Nancy Wyman, who chairs Access Health’s board, released a statement Wednesday to “reassure Connecticut consumers” that the exchange will continue operating as it has.
“If there are any changes in the federal [Affordable Care Act], we will address them – and, as always, the priority will continue to be ensuring affordable, accessible, high-quality health care for our residents,” she said.
Connecticut policymakers have generally embraced the elements of the health law, which, as a whole, has never proven popular with the general public. The state was the first to expand Medicaid – under a Republican governor – and built what has generally been considered to be one of the better-functioning exchanges.
Some aspects of the health law were later written into state statute, including the prohibition on denying coverage to minors with pre-existing conditions and the ban on imposing a lifetime cap on a person’s coverage. (State law only governs about half the health plans in the state, however, because many employers self-insure their policies, making them subject to federal law but not state regulation.)
But the major aspects of Obamacare – the subsidies that discount coverage for thousands of Connecticut residents and Medicaid coverage now available to a broader group of poor people – rely on hundreds of millions of dollars in federal funding.
The impact of any plan to repeal, replace or change Obamacare will depend on the details, of course. Several supporters of the health law said there’s room for changes that could be agreed to by both parties.
Wadleigh noted that Trump has called for allowing insurance plans to be sold across state lines – something that could bring new carriers to Connecticut, although critics say it could be problematic because if the multi-state plans are not subject to mandates to cover certain benefits, they would draw healthy customers, leaving sicker, costlier customers in the other plans and drive up costs.
Connecticut’s two Democratic U.S. senators said Wednesday that there are ways to improve the law that could garner bipartisan support. Sen. Richard Blumenthal said he sees potential for “common sense agreement” to improve the law by, among other things, improving tax credits for business and increasing subsidy options for consumers. Sen. Chris Murphy said that since Republicans are unlikely to take action that would drop 20 million people’s coverage, they will probably end up with a measure that won’t look much different from Obamacare.
“I think in the end, we may be talking about modifications to the existing law, because there’s no easy way to replace it with something that looks radically different unless Republicans are willing to do Medicare for all,” Murphy said. “They likely aren’t, so we’re probably going to be back to talking about modifications.”
Laszewski takes a different view.
“I know there are people out there saying it won’t be repealed or replaced,” he said. “It will be repealed and replaced, and people need to get their heads out of the sand. That’s the mandate. They won the election. Elections have consequences.”
He expects the effort to begin with House Speaker Paul Ryan’s plan. It would, among other things, give people tax credits to purchase insurance from a wider choice of sources – rather than limiting them to public exchanges – and allow insurance to be sold across state lines. It would expand the use of health savings accounts that can help people with catastrophic coverage pay for care, and would spend billions of dollars in federal money to fund high-risk pools. It would also maintain the requirement that people be allowed to buy coverage regardless of their medical history, and allow young adults to stay on their parents’ plans until age 26 – two popular provisions of Obamacare.
One thing Laszewski thinks is certain: Any plan will have a transition period for those who currently get coverage through Obamacare.
“Twenty million people can’t lose their coverage,” he said.
Cox thinks some aspects of Obamacare are likely to be continued, and pointed to the popularity of the provision requiring insurers to allow people to buy coverage even if they have pre-existing conditions.
“It’s just hard to be able to implement that without some sort of incentive to get the healthy people to buy into the market,” she said. “And so if we want a market-based approach to expanding health insurance coverage, part of that is going to include some aspects of the law that are popular, like the ability of people with pre-existing conditions to get insurance, but also some sort of incentive to get the healthy people to buy insurance so that people don’t just wait until they’re sick to get coverage…What’s been so contentious is how to go about doing that.”
In the meantime, Wadleigh said, Access Health is operating the way it did the day before the election. But now officials must determine how potential changes affect its plans for the future.
“I think the question for me right now is, as an organization, do we move forward like nothing changed and say, ‘Hey, here are all the things we want to do to stabilize and improve the business climate for Access Health as an exchange,’ or do we take a wait and see perspective, or do we try to make some minor tweaks to continue to try to improve it?” Wadleigh said. “And the answer is I don’t know.”
And the election results don’t immediately change one underlying problem, he added.
“The cost of health care is spiraling upwards,” Wadleigh said. “This problem isn’t going away with a new president.”