Elizabeth Munnich
Elizabeth Munnich

President-elect Donald J. Trump will have a tough time repealing the Affordable Care Act — but he and the Republican-led Congress can remove critical parts of the law that could contribute to its collapse, a University of Louisville professor said.

“Repeal is going to be difficult” for President Trump, but “there’s a lot he can do,” said Elizabeth Munnich, assistant professor of economics at UofL.

At this point, she said, the health care and health insurance industries are facing a lot of uncertainty, and predicting the effects of policies that have not yet been proposed or even articulated is difficult.

“We don’t know a lot about what Trump is going to do,” Munnich said. “I don’t think there’s a lot of consensus about what his priorities are in terms of health care reform.”

Trump could change some aspects of the law simply through his cabinet appointments, she said.

For example, the ACA requires that health plans offer certain essential health benefits, but details of the requirements are the purview of the secretary of Health and Human Services, and Trump’s appointee could simply declare that insurers no longer have to require paying for birth control. Munnich said conservatives have for years complained about that provision, which requires men to pay for birth control they’re not using and, opponents of the law argue, may infringe upon employers’ religious freedoms.

Trump also could loosen portions of the law that prohibit insurance companies from charging premiums based on a patient’s risk for health problems. The ACA allows insurers to charge different premiums based only on tobacco use and age. And plans for older Americans cannot cost more than three times as much as those for younger customers. Even if that were changed, however, Munnich said it would not have a big impact on health care costs.

A bigger issue that looms, she said, is the fate of the individual mandate, which requires that people sign up for health insurance or face a penalty. The mandate was supposed to help insurance companies pay for other parts of the law, including the prohibition against discriminating for pre-existing conditions and the permission for people under 26 to stay on their parents’ policy.

The mandate, which Trump wants to eliminate, has not worked very well, because it has compelled too few young, healthy individuals to sign up for health insurance. The idea was they would offset some of the costs that insurers incurred from older, sicker people who have readily signed up for insurance plans through the ACA, because they desperately needed health care, but had not been able to afford it. The ACA provides many people with federal subsidies to defray the cost of premiums.

Insurers including Louisville-based Humana have said that they are losing hundreds of millions of dollars this year on the patients who have signed up for the ACA. For next year, many big insurers, including Humana, have reduced the number of plans they are offering to limit their exposure to ACA-induced losses.

For Kentuckians who obtain health insurance through the ACA, that has meant less competition: In more than half of the state’s counties this year, individuals can buy health insurance from only one provider: Anthem.

But without the individual mandate, Munnich said, the question becomes how insurance companies can generate enough revenue to pay for the parts of the law that Trump wants to keep. And so far, the GOP has not said with what it wants to replace the individual mandate.

Aetna CEO: Parts of Obamacare, health care challenges will remain

Mark Bertolini
Mark Bertolini

Humana declined to talk about how Trump’s election might affect the ACA, but told IL via email that it planned to continue its “long history of working with leaders on both sides of the aisle — in the interest of our members.”

For Mark Bertolini, CEO of Aetna, the Hartford, Conn.-based insurance giant that wants to buy Humana, the election of Donald Trump was a big surprise.

Bertolini said in an interview at last week’s New York Times DealBook Conference that among all the possible outcomes the company expected, “This one wasn’t even on the sheet.”

Bertolini said he expected Trump and the GOP-led Congress to repeal the ACA, “at minimum in name.”

He assured people who are signing up for health care now that they would be able to keep their insurance through at least 2017.

The CEO also said he expected some provisions of Obamacare to remain.

The expansion of Medicaid, the prohibition against turning down or kicking customers off insurance because of so-called pre-existing conditions, and allowing young adults to remain on their parents’ policies “are all very important programs that we need to continue,” Bertolini said.

The challenge, he said, will be trying to figure out how to get those provisions to remain.

And, the CEO said, the country will have to figure out what it plans to do with the people who have signed up for health insurance through Obamacare.

“I don’t think you can take … 17 to 20 million people, you can’t put them on the street without insurance,” Bertolini said.

There are many people, aged 45 to 65, who have chronic conditions and cannot afford their insurance outside of the exchanges, he said. Hillary Clinton’s solution for those people, to extend Medicare, the nation’s insurance program for the elderly, to people age 50 and older so long as they pass a means test, “is a reasonably good solution,” Bertolini said.

Whatever happens with the Affordable Care Act, Bertolini emphasized that the nation still had to tackle big health care challenges.

“Eighty-one percent of the American public hate their health insurance. They hate the health care system. We have too many uninsured. It’s not affordable, even for people making six figures. So it still has to be fixed,” he said.

“The approaches will be different from a policy standpoint and a funding standpoint, but we still need to have a product that’s affordable, more personalized, simpler to use, that people can buy like they buy everything else today.”

Boris Ladwig
Boris Ladwig is a reporter with more than 20 years of experience and has won awards from multiple journalism organizations in Indiana and Kentucky for feature series, news, First Amendment/community affairs, nondeadline news, criminal justice, business and investigative reporting. As part of The (Columbus, Indiana) Republic’s staff, he also won the Kent Cooper award, the top honor given by the Associated Press Managing Editors for the best overall news writing in the state. A graduate of Indiana State University, he is a soccer aficionado (Borussia Dortmund and 1. FC Köln), singer and travel enthusiast who has visited countries on five continents. He speaks fluent German, rudimentary French and bits of Spanish, Italian, Khmer and Mandarin.