When asked in recent months about how the outcome of the election would impact health care, I have replied, “Not much if Clinton is elected, and not much unless Trump is elected and the Republicans maintain control of both houses of Congress, but I don’t hear many predicting that combination of events will occur."
Fast forward. Here we are, hours after the election, and Donald Trump is president-elect and the Republicans have maintained a majority in the House and Senate.
President-elect Trump has often repeated the mantra, “we must repeal and replace Obamacare."
But the presidency has a way of moderating extremes. It is one thing to make campaign promises that fuel one’s base of supporters; it is an entirely different matter when you are the president of all Americans and are now going to revisit the health insurance coverage that 20 million Americans got under the Affordable Care Act. Even so, a repeal requires an act of Congress.
I have little doubt that the House of Representatives will be able to muster the votes to repeal the Affordable Care Act. They have already done so something like 50 times.
The tricky part will be with the “replace” part of the equation. While Mr. Trump has mentioned incentivizing the use of health savings accounts, providing tax credits for the purchase of insurance and allowing insurance companies to sell their products across state lines, he has offered few details. There remain many questions, such as whether he and House Republicans would preserve features of the Affordable Care Act that have been very popular – e.g., the requirement to insure individuals regardless of their underlying medical conditions, the ability of children to remain on their parents’ health insurance until age 26 and the abolition of annual and lifetime caps.
Then there is the Senate. The Republicans retain only a slim majority and not enough to overcome a filibuster. Many senators will face reelection in two years. Will they be willing to vote to repeal the Affordable Care Act if their state is one of the states that has benefited from the ACA? On the other hand, are there Democratic senators who have fallen in line up to this point to support their party’s president while in office, but who might be willing to vote for repeal if the replacement plan addressed many of the known problems with the Affordable Care Act while preserving many of the successful features of the law?
Regardless of where representatives and senators fall along political lines, there is the practical problem of the Congressional Budget Office scoring. The CBO scores legislation to project the financial impact of the legislation. Currently, the CBO projects that repeal of the Affordable Care Act would increase federal budget deficits by $137 billion over the next 10 years.
Most Republicans do not support increasing the deficit, and Republicans’ replacement legislation would need to generate savings of at least $137 billion over the next 10 years to remain budget neutral. This is likely to be a high hurdle in coming up with the legislation to replace the Affordable Care Act.
All along, St. Luke’s has taken the position that the ACA was primarily insurance reform, and it seemed unreasonable to us that you could add tens of millions of people to the ranks of the insured in a broken healthcare delivery system and expect that somehow the government would save money.
But we are well into the implementation of the Affordable Care Act, insurance reforms have been put into place and there is now a marketplace in every state for people to shop for health insurance on the insurance exchanges.
Instead of repeal, St. Luke’s would like to see tweaks that address the weaknesses of the law, while preserving the good parts. My guess is that the most likely “repeal and replace” approach is going to be a repeal and replacement with a law that looks a lot like the Affordable Care Act, but with provisions to address the law’s weaknesses.
Regardless, and while we wait to see the direction our new government goes in, St. Luke’s strategy remains unchanged. We are focused on achieving the best outcomes for our patients at the lowest total cost of care. It may just be that with the Republicans’ desire to reduce regulation, the path toward these goals becomes less complicated.
David C. Pate, M.D., J.D., is president and CEO of St. Luke's Health System, based in Boise, Idaho. Dr. Pate joined the System in 2009. He received his medical degree from Baylor College of Medicine in Houston and his law degree from the University of Houston Law Center.