By Ethan Gregory, Staff Writer
Ever since the Affordable Care Act, known colloquially as Obamacare, was enacted, Republicans in Congress have been fighting to have it completely repealed. The line has become a major talking point for every Republican candidate for almost every office for six years, as the inevitable veto threat from President Obama rendered a repeal vote in Congress essentially meaningless. Republican politicians received the political upside of voting for repeal without any threat of real-world consequences.
That all changes on January 20, 2017, when President Donald Trump takes office. Will the GOP “repeal” Obamacare? Yes, they probably will, or at least that is how they will sell it to the Republican base and American people. In part, it may be true, but I expect many of the most important provisions of the Affordable Care Act to remain intact. Important aspects of the ACA such as requiring insurance providers to accept individuals with pre-existing conditions, allowing young adults to stay on their parents’ plans until age 26, and many other accessibility pros must remain in place unless the GOP wishes to feel an angry revolt from the American people in the 2018 midterms and 2020 general election. President Trump, however, could actually be key to solving some of the issues that are holding back American healthcare.
Three of the biggest challenges that face Obamacare are the resistance from Republican-controlled states to expand Medicaid, the continuance of increases in healthcare costs, and the incredibly unpopular individual mandate.
As of today, thirty-one states and Washington D.C. have expanded Medicaid to close the insurance gap by covering all families and individuals that earn less than 138% of the federal poverty line under Medicaid. That leaves nineteen states that have not adopted Medicaid expansion, almost all of which are completely Republican-controlled, and the majority of which are Southern states such as my home of Alabama (which is, ironically, a state in dire need of this expansion).
In these states, the issue with expansion is not as much resistance to the idea of expanding Medicaid as it is resistance to accepting a program with the word “Obama” in it. That is where President Trump comes in. A Trump administration and Republican congress can tweak certain aspects of the ACA while still presenting the front of having repealed Obamacare, a major campaign promise of his. Republican-controlled states, especially Southern states that are in dire need of healthcare expansion, will be much more amenable to the idea of expanding Medicaid and closing the healthcare gap when doing so is not associated with Barack Obama. The President-Elect has stated that he wants to use Medicaid to provide health coverage to people that cannot afford private insurance, thereby embracing Medicaid expansion. In fact, according to Donald Trump’s campaign website, he plans to “block-grant Medicaid to the states,” so that states will have the necessary resources and can expand Medicaid as best fits each state without overly burdensome federal regulations which currently deter some states. Trump has not said if he supports the current policy of covering up to 138% of the poverty line, but does leave the door open for Medicaid expansion, albeit perhaps not to Obamacare’s high requirements. By block-granting Medicaid to states and reducing the federal regulations surrounding the expansion, states may be more willing to use their funding to expand Medicaid to more low income people in ways that best fit their state’s interests and obligations.
The second concern that has risen from the ACA is the continuance of increases in healthcare costs, including a 25% increase for many in 2017. Again, enter Donald Trump; the President-Elect has presented policy tweaks that would lower the costs of healthcare for private buyers. One of those tweaks is allowing insurance to be sold across state lines. Such a policy allows individuals more choices in the healthcare marketplace. For example, some states mandate coverage for autism within their state while others do not. For a single, late 20’s male without autism in a state that mandates autism coverage, there is no need to have health coverage for autism. Dropping the restrictions on selling across state lines would have substantial cost reduction effects for that individual and others in similar situations. There may be a balance that must be struck between optional and mandated coverage of certain diseases, but that balance cannot be found until we drop the restrictions on selling across state lines.
Competition has also dissipated across many areas which has lead to spikes in costs. Entire states such as Alabama, Oklahoma, and South Carolina only have one insurer competing in the ACA exchange. In many other counties across the nation, there are only two insurers participating at most. By dropping the selling across state lines restriction, major insurance companies will have to begin competing which will lead to a drop in cost for consumers and more affordable costs for millions of Americans that live in monopolized areas.
In addition, the potential expansion of Medicaid by states under the Trump administration could cut costs for everyone. Private healthcare marketplace costs in states that had expanded Medicaid are around 7% lower than in states that have not expanded Medicaid. Poorer people tend to not get regular checkups or preventive care, which in turn drives up the costs of private insurance plans when they do not have access to Medicaid in states that have not expanded it. By embracing expansion, poorer people are taken out of the private marketplace, costs to insurers go down, and premiums decrease while coverage increases.
Replacing the individual mandate with tax incentives is another policy Republicans have embraced when confronting healthcare reform. Americans have never welcomed being penalized for making individual decisions and typically do not respond well to it. That has been no different with regards to the individual mandate of Obamacare. It is no secret that the mandate is one of the most unpopular aspects of the ACA, but the worst part is that it is not even driving people to purchase insurance in the first place. To be effective, the penalty would need to be hundreds of dollars more, assuredly making the individual mandate, and by association Obamacare, even more unpopular. It is time to explore other options; tax deduction incentives could be the answer, for Americans might be more responsive to tax breaks than stiff, government-imposed penalties.
One thing of which we can be certain is that healthcare is going to change over the next 4 years. Many on the left are fearful that the Republican control of the Executive and Legislative branches means certain death for President Obama’s legacy program. I contend that it will die in name only. Yes, substantive reforms will be made, but the extent of government subsidized healthcare will not decrease dramatically. I am confident that American healthcare will continue to improve, and a Donald Trump presidency will be exactly what American health care needs.