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Will Trump’s policies hamper or improve healthcare access? Experts weigh in.
For the majority of the U.S. population, access to healthcare is about having the financial means to access the provider system, according to one expert.
“This means that people need affordable health insurance coverage,” says Rosemarie Day, president of Day Health Strategies. “Access to healthcare was greatly increased by the Affordable Care Act [ACA] by increasing the number of insured people-through insurance subsidies and other provisions, eliminating the insurance exclusion for pre-existing conditions, and eliminating lifetime caps on insurance. Without insurance coverage, most people simply can’t afford to seek medical treatments.”
With repeal and replace waiting in the wings, Day believes that the Trump administration, and Republicans in Congress, could reduce this access.
“For those that have proposed replacement options, most will not provide the same level of insurance coverage that the ACA currently does-both in terms of number of people covered and the amount of subsidies,” she says. “One exception to this appears to be the Cassidy-Collins proposal [the GOP replacement plan], but the full details on this are not yet available.
Council for Affordable Health Coverage (CAHC) President Joel White sees things a bit differently. “Obamacare’s architects promised lower costs-premiums would go down by $2,500 per family-but the savings never materialized. President Trump has said he is committed to making health coverage more affordable and more available to all Americans, and we take him at his word.”
1. The ability of individuals to acquire healthcare insurance could change.
“This, in turn could depress utilization of healthcare if individuals cannot afford it,” says Matt Fisher, chair of the Health Law Group at Mirick O’Connell.
Day agrees. “The Trump administration has the potential to greatly reduce access to healthcare for some of our most vulnerable citizens: those whose jobs don’t offer health insurance and who don’t make enough money to purchase insurance on their own,” she says. “This is at least 20 million people who gained coverage through the ACA, including the Medicaid expansion. This will only happen if Trump follows through on his promise to repeal the ACA and ends up replacing it with something less. It’s tough to say, since we don’t yet have details on his plans. But we know that most Republican replacement plans that have been proposed in Congress are less robust than the ACA. And it’s worth noting that any ACA repeal/replace plans the president puts forth will have to be supported by Republicans in Congress.”
2. Medicaid expansion could be affected.
“Perhaps the biggest potential impact on access to care is what the administration decides to do with Medicaid expansion,” says Managed Healthcare Executive advisor Don Hall, principal, Delta Sigma LLC. “A decision to continuing allowing states to expand coverage could significantly improve access to care in states that did not do so under the Obama administration. Conversely, rolling back the expansion through a modification of Affordable Care Act would do the opposite.”
3. The individual mandate could be affected.
“Doing away with the individual mandate currently required under the ACA would have a negative impact of plans offered through the state healthcare exchanges and likely result in a discontinuance of guaranteed issue,” Hall says.
4. Providers could bear the brunt of costs for treatment of more uninsured, and therefore, access could decline.
“If providers are not paid, resources could become strained and care not offered or provided to individuals who do not have an ability to pay,” says Fisher.
5. The Medicare Advantage Value-Based Insurance Design demonstration could be expanded to all 50 states.
“This pilot test, currently ongoing in 10 states, lowers consumer cost-sharing to encourage the use of high-value clinical services and providers,” says A. Mark Fendrick, MD, professor of internal medicine in the School of Medicine and a professor of health management and policy in the School of Public Health at the University of Michigan. “There is bipartisan support in the House and Senate for the expansion.”
6. IRS regulations that restrict pre-deductible coverage in health savings accounts (HSAs) could be expanded to include more services.
This, coupled with more flexibility for high-deductible health plans (HSA-HDHP) to cover more services before meeting the plan deductible could enhance consumer choice and improve access to high-value care. “HSA-HDHP are a top health policy priority of the Trump Administration, and in their current form, make it expensive for consumers to access important services that manage chronic diseases-e.g., diabetes, cancer, depression,” Fendrick says.
Based on a leading proposal from HHS Secretary Tom Price, and comments from other congressional Republicans, Eugene Sayan, CEO and president of Softheon, also expects HSAs to be a major component of "TrumpCare’s" attempt to provide greater access to coverage.
"If Price’s Empowering Patients First Act [H.R. 2300] is pursued, the measures would provide a one-time tax credit of $1,000 and an expansion of Americans’ eligibility to participate in HSAs beyond those who have a high-deductible health plan," Sayan says.
7. The Essential Health Care Benefit package could be modified.
The Essential Health Benefits must be offered at no dollar limits on every plan under the ACA. “The law states that the “Secretary shall define the essential health benefits…” It goes on to define 10 categories that must be included,” says G. William Hoagland, senior vice president, Bipartisan Policy Center. “I believe the Secretary within limits can redefine the level of benefits that must be included in a health plan offered on the exchange. If those benefits are reduced, reducing costs, then it is possible that the take up-access-would increase due to the price sensitivity of the health plan.”
8. The 3:1 age band ratio could be modified-with limited authority.
The age band rating establishes a range for which insurers can assess higher premiums from older consumers over younger, healthier ones to cover increased costs. One provision in ACA compresses the permitted age band rating to a 3:1 ratio.
According to Hoagland, the ACA allows rates to vary based on age within a ratio of 3:1 for adults, defines permissible age bands, and provides for a default uniform age curve to be established in guidance.
“One of the arguments for young people not signing up has been the price of the plan,” Hoagland says. “The law allows within limits the Secretary to age adjust premiums. Adjusting the age ban so that the premium for younger folks is reduced could increase take up and coverage. And the greater the take up of the younger, healthier population would result in overall premiums being reduced and therefore increasing coverage and access.”
Day adds: “While adjusting the age ban could increase participation from young people, it could also have an adverse effect as older people would face more-expensive coverage and would be less likely to participate.”
9. The “grace period,” a 90-day window that requires insurers to cover consumers who aren’t paying their premiums, could be reduced.
“This would help maintain coverage, stop the in-out activity, and I would argue have the salutary effect of reducing premiums overall that would encourage more sign-up and coverage,” Hoagland says.