What that will look like remains unknown. To fully repeal the ACA, Republicans would need 60 filibuster-proof votes in the Senate. However, Republicans have just 51 seats to the Democrats’ 45 after the GOP lost two seats in the November election.
House Republicans can push through a bill using a legislative maneuver called reconciliation, but it requires a majority vote in both chambers and would be restricted to changes that have an impact on the federal budget. At a minimum, Republicans would need a budget before they could attempt this strategy.
They achieved this in late 2015, drafting a bill (H.R. 3762) that would have eliminated Medicaid expansion and the subsidies that currently help 83% of enrollees on the ACA exchange afford their premiums. President Obama vetoed the bill; President-elect Trump is unlikely to do the same.
However, he and Republican party leaders must first come to agreement over what their version of health reform should look like. In general, Republicans have called for a healthcare system rooted in the free market, with more individual responsibility, less regulation, and more flexibility.
For instance, Rep. Ryan’s planwould restrict insurers from denying patients with preexisting conditions but only if individuals maintain continuous coverage, with a one-time open-enrollment opportunity.
Campaign Promises Versus President-Elect Promises
While campaigning, President-elect Trump proposed a seven-point plan that included lifting restrictions on tax-free health savings accounts, providing tax deductions for health insurance premiums, allowing the sale of health insurance across state lines, requiring physicians and hospitals to be transparent about pricing, and eliminating the individual mandate to purchase health insurance. He also proposed converting Medicaid into block grants to states and vowed not to change Medicare.
As president-elect, he has pledged, with few details, to challenge abortion access, further research and development, provide “flexibility” to Medicaid, “modernize” Medicare, and reestablish high-risk pools for sick patients with traditionally high premiums. 1 The ACA does not currently allow insurers to charge sick patients higher rates than healthy ones.
While block grants are one option for attempting to control costs in Medicaid by providing states a fixed sum to administer the entitlement program, Rep. Ryan’s plan calls for another option: per-capita limits on enrollees on Medicaid. He has not detailed what those limits would be. What will happen in states that expanded Medicaid through the ACA relative to those that did not is also unknown.
“Frankly, I think that what this election showed is a complete disdain for the general establishment,” says Dr. Lenchus. “If they do give money to state legislatures, I don’t know if I trust them any more to manage that money than the feds, where they could be robbing that block grant for general revenue.”
While President-elect Trump has not yet provided more information about his plans for Medicare, Republicans in the past, including Rep. Ryan, have proposed offering premium support to beneficiaries (sometimes called a voucher or defined contribution), a fixed sum given to Medicare participants to use toward premiums under traditional Medicare or Medicare Advantage plans.
While this could reduce beneficiaries’ out-of-pocket costs, according to the CBO, spending could also increase and beneficiaries may pay variable out-of-pocket costs. Direct spending, meanwhile, would increase by $879 billion over the next decade if all the ACA and its changes to Medicare are eliminated, hastening depletion of the Medicare trust fund.2
“Frankly, I would not be opposed to seeing a sort of sliding scale for Medicare,” says Dr. Lenchus. “If you’re Warren Buffet taking $150 a month for Medicare, do you need to do that? That $150 spread to three other people who are barely making ends meet could make the difference for them taking a lifesaving medication that month.”