There's every reason to believe that what we know as the Affordable Care Act, President Obama's central achievement, won't survive Trump's presidency. While President-elect Trump's campaign pledge to have Congress repeal Obamacare on day one isn't technically feasible, it's likely he'll largely dismantle this capstone progressive program, thanks to the supportive Republican Congress he'll enjoy (at least until the midterm elections).
While I fear greatly for my patients, this potential decision, while highly risky, could at least mean an end to the political gridlock surrounding health care that also represented a pressing threat to quality medicine.
As someone who practiced medicine both before and after the ACA, I've witnessed its highs and its lows. I once treated a man who'd suffered a large brain bleed in a fall down a staircase. He struggled in the hospital through numerous complications over the course of months, and with our help, his family was able to apply for and receive commercial insurance coverage in his home state while he was still in the hospital.
This coverage, which they got over the Obamacare exchange, meant he was able to get the equipment and therapies he needed to successfully transition home with his family. This was miraculous because before Obamacare, he would have had to apply for Medicaid coverage, which would require becoming destitute if he was not already, and remaining poor if he hoped to keep coverage that he either could not get or could not afford on the private insurance market.
Conversely, a colleague of mine recently treated an entrepreneur who covered herself through an exchange policy while building her business. She thought she bought a quality plan, but when she suffered a spinal cord injury in a car accident that caused significant paralysis and necessitated prolonged rehabilitation, she found that her ACA plan capped her rehabilitation coverage at an arbitrary 30 days.
Now, limits on rehabilitation coverage aren't uncommon even in insurance plans outside the exchange, but they can sometimes be successfully appealed with proper documentation and when physicians lay out a good case to insurance medical directors. An appeal wasn't even possible with this low-quality insurance plan, which enforced an arbitrary, black and white, calendar-based cutoff, no matter how much clinical improvement was happening, or what the medical evidence supported.
The presidential campaign concluded with a lot of focus on health care, with headlines about large, upcoming premium increases attracting enormous attention. President Obama and Hillary Clinton never successfully communicated to the nation that they understood the problems with the ACA and were trying to improve it, but were repeatedly thwarted by Republicans in Congress. Too many voters got the impression Democrats considered the ACA to be flawless.
The final presidential debate also featured Trump's poor understanding of late-term abortion, reminding much of the electorate about the power the new president will have to select justices to the Supreme Court who will share his views.
Whatever voters intended in selecting Donald Trump, no one casting a ballot for him should have been unaware that he represents a radical change from the path that President Obama selected in forging the ACA and that Hillary Clinton wanted to continue.
After the election, one patient's mother expressed concerns to me about her son's ability to get health insurance in the future, if Obamacare were abolished, given that the injury that brought him into my care would be considered a pre-existing condition. This concern is adding stress to an already overwhelming situation, as she ponders whether an elective procedure should be done now or whether they should wait to see if the problem he's having now resolves on its own or becomes more problematic in the future, as we have advised.
Health care analysts have observed
that unlike other elements of Obamacare that President Trump and his supportive Congress might easily drop through budget reconciliation (such as the exchanges), removing the ban on exclusions to pre-existing conditions requires passing legislation through the Senate.
Democratic senators could filibuster such repeal legislation, and Republicans don't have the 60 votes necessary to break that filibuster, but Republicans intent on killing the ban could simply change
the Senate rules to prevent a filibuster in the first place.
They could also choose to attach repeal legislation to other essential legislation, forcing its passage.
What's more, the Trump administration would likely drop the Obama administration's appeal of House v. Burwell
, meaning the federal district court ruling that exchange insurance subsidies aren't constitutional will stand.
But even without these possible maneuvers, if Trump kills the insurance exchanges, and along with them the subsidies necessary to make health care plans affordable, Obamacare is over. You cannot mandate that individuals purchase insurance they cannot afford, and you cannot force insurers to cover anyone who comes knocking if there isn't a mandate forcing plenty of healthy people to offset their costs by buying into the system.
As for a replacement for Obamacare, Trump was famously vague on the campaign trail about what he intends to do, other than declaring it will be awesome. There's a four-page policy brief on his campaign website
, and the Trump administration's new transition website, GreatAgain.Gov, features a few bullet points
But if, as he has threatened, he's going to get rid of every last vestige of the ACA, he would be "protecting people's right" to do something monumentally stupid: live life free of medical insurance coverage. As doctors like me know all too well, that plan works right up until the minute it doesn't.
Trump's policy wonks talk a lot about the wonder of the free market, and how, unshackled from the concerns of a conscientious government, insurance companies will see it in their best interest to offer affordable care to everyone. Trump believes in trickle-down health care.
He has alluded to allowing insurance companies to offer their plans across state lines, facilitating price comparisons among hospitals and doctors, letting you sock away money in health savings accounts that won't disappear, allowing you to share your HSA with your family and pass it on in your will, and letting you deduct the costs of health insurance from your taxes.
These are great moves for people who are making good incomes and can engage in that free market. But it's very similar to what we had before. Though some consumers will have more money in their pockets to shop, and they might have a few more choices while shopping, Trump has been adamant that he won't force insurers to sell to everyone.
And you would not be able to access this free market even if you're well off if you have a pre-existing condition. In the free market we had before Obamacare, insurers said "no thanks" to 1 in 5 potential customers
because those customers had conditions insurers didn't want to cover.
In a sign of how unpredictable this presidency is going to be, while none of Trump's policy statements discuss preserving the pre-existing condition protections of the ACA, or the ability of parents to keep their children on their plans until age 26, Trump told the Wall Street Journal on Friday
that he's now supportive of keeping these provisions. President Obama managed to persuade Trump of their importance during their 90-minute meeting Thursday, a remarkable feat given that a year and a half of policy debates on the campaign trail did nothing.
In this,Trump is starting to sound a lot like the typical American voter, who supports individual provisions of the ACA but suddenly dislikes the law the minute it's revealed to be Obamacare. But how might a free marketeer like Trump force insurers to take on bad risks outside the ACA?
For that, we can look back to his previous policy statements. Instead of being able to shop around on the open market with your pre-tax dollars and your HSA account, you'll probably be relegated to something called a high-risk pool.
The high risk pools were very limited state-based markets that feature high premiums. High risk pools require tax dollars to work, just like Obamacare, and the Trump administration would have to expand them enormously to make up for the loss of exchange plans.
They're quite simply a far more inefficient, inequitable and unaffordable way to do what the ACA has done.
Democrats will still be a factor in the next wave of health care reform, but Trump has every tool he needs to remove everything President Obama did and issue radically different policies. The ACA and Medicare were headed down a path of transforming hospitals and clinicians
into money managers and quasi insurance companies that would need to weigh one patient's needs versus another's, and that trend concerned me enormously.
I don't think President Trump will continue that effort so vigorously, and that's something.
But I'm deeply worried that Trump's blind allegiance to unfettered capitalism won't mesh with quality medicine. The people he surrounds himself with will matter quite a lot, and so far he isn't distancing himself from the odd ducks who encircled him during his campaign. So I worry that somebody like Ben Carson as head of the Department of Health and Human Services would spend more effort on blocking access to care because of his extreme religious beliefs than finding efficiencies.
And don't get me started on green-coffee-bean-extract-swiller Surgeon General Mehmet Oz. After what's coming, we may all need a detox cleanse.