Here's What Could Happen to Healthcare While Congress Squabbles Over the ACA Repeal

Back in 2015, a year after the insurance provisions of the Affordable Care Act (ACA) kicked in, I had some fun predicting what the changes might mean long-term for patients, providers, and hospitals.
Was I right? Well, it's looking less and less likely that we'll ever find out.
In January, the Republican-controlled Congress passed a budget resolution that could be the first step in repealing the ACA. This process, which requires only a majority vote to pass, allows lawmakers to rewrite ACA provisions related to spending, revenue, and federal debt.
However, getting the resolution through Congress proved more difficult than Republicans expected. It definitely exposed deep-seated divisions within the party and uncertainty over what — if anything — should replace the ACA.
So what will the coming years hold for us as administrators, providers, and patients? Here are six predictions for 2017 and beyond:

1. Republicans will spend a lot of time (maybe years) at the drawing board.

The ACA has three major aspects that work together to expand coverage while keeping the insurance market viable:
  • Tax subsidies
  • Individual mandates
  • Consumer protections
President Trump has expressed support for repealing the ACA's individual mandate and tax subsidies. However, he’s said he’d like to retain the consumer protections that guarantee coverage for dependents under age 26 and people with pre-existing conditions.
However, experts argue that the subsidies, mandate, and consumer protections are like the legs of a three-legged stool. Take away any one leg, and the whole thing collapses underneath you.
In theory, Republicans could eliminate subsidies and the individual mandate plan through the budget reconciliation process. But without a robust coverage pool to offset increased costs, insurers would be forced to raise premiums — perhaps to levels where no one could afford health insurance.
Many Republicans appear uncomfortable with any move that might destabilize the insurance markets, so it will be interesting to see how they walk this particular line.

2. Nothing will happen fast.

Government moves slowly.
In order to alter the consumer protections prong of the ACA, Congress will likely need to use the regular legislative process (as opposed to budget reconciliation). Any replacement bill will need to be sufficiently bipartisan to swing at least a few Senate Democrats and break a potential filibuster.
But even among Republicans, there seems to be a lack of consensus on how to move forward. Consider that in the six years opponents have been demonizing the ACA, they have produced exactly zero viable replacement bills.
Republicans do appear to be moving away from their “repeal and delay” strategy that had industry experts, voters, and moderate Republicans squirming.
Speaker Paul Ryan says his party can produce a replacement plan within 100 days. However, that’s a very ambitious timeline for a legislation of such complexity and import. Another option would be to pass a repeal bill that kicks in a few years down the road, allowing more time to draft a viable replacement.

3. Reimbursements to hospitals and hospital-based physicians will decline.

As hospitals everywhere are painfully aware, “self-pay patients” are often no-pay patients. And no matter its faults, the ACA was very effective at raising coverage rates.
Take California, for example. In late 2013, 22 percent of the population was uninsured.
Then the insurance exchange and Medicaid expansion went into effect in 2014. Within weeks, the percent uninsured dropped to 11. Today it's in the single digits.
Granted, Medicaid reimbursements aren’t enough to keep the lights on at most private practices. But they were a boon for hospitals and hospital-based providers who serve as our healthcare safety nets.
Case in point: following the Medicaid expansion, California's uncompensated care fund actually grew for the first time in decades, rising by about 10 percent. While payments remain low (about 15 to 20 cents on the dollar), they likely strengthen the safety net by helping EDs in underserved communities attract specialists to their call panels.
If the Medicaid expansion is rolled back, hospitals will need to retool their business plans to allow for smaller reimbursements. This is unfortunate in a time when we’re facing access issues and a shortage of healthcare providers.

4. EDs at public hospitals will see an influx in visits.

When the ACA expanded coverage in 2014, a curious thing happened in Los Angeles’ EDs.
Most private hospitals saw a modest uptick in patient volume (about 5 to 10 percent over 2013 levels). However, visits to county EDs declined, dropping as much as 8 percent in the cases of some USC and UCLA hospitals.
While the exact reasons are hard to pinpoint, it's likely the newly insured patients now had more options for care. Now that they could choose, they gravitated toward locations they perceived as having shorter wait times.
In the event that the coverage provisions of the ACA are rolled back, I’d expect to see this pattern reverse itself. People who lose their coverage (potentially up to 18 million in year one) will again depend on public hospitals for care. This means our safety net facilities will need to absorb more patients at lower reimbursements.

5. We'll all continue to pay a high price for chronic disease.

It’s too soon to tell if the ACA had any robust effects on population health. But experience suggests that health improves significantly when people gain insurance coverage.
A few years before the ACA, some California counties created a program to expand healthcare coverage among low-income residents. Many of the newly insured hadn’t seen a doctor in years.
For the first three months of the program, ED utilization among new insureds shot up dramatically (about 600 visits per 1,000 enrollees). However, within two years rates dropped to 183 per 1,000 — near the average among insured Californians.
So what happened? It's probably safe to say that many people in this population had delayed needed care. At first, they used the ED to address their untreated conditions. But thanks to improved access, they got their conditions under control and had fewer exacerbations.
They also learned to navigate the healthcare system rather than relying on the ED as their frontline provider.
A rollback of ACA coverage would be unfortunate, because chronic diseases account for 70 percent of deaths and 86 percent of U.S. healthcare spending. If 18 million people — or even 2 million — lose their insurance, we all may lose a golden opportunity to improve public health and rein in our long-term healthcare costs.

6. Advocacy will change everything.

The decisions our lawmakers are faced with could have a huge impact on our careers, practices, and patients. So as healthcare providers and frontline experts, it’s important that we make our voices heard.
One of the best ways you can do this is through your professional organization. AHA, AMA, ACEP, SHM, SEMPA, ASA, and other specialty groups have advocacy sections that promote responsible, ethical policymaking. Even if you’ve been a long-time member, consider ramping up your involvement.
Another thing you can do is to raise awareness about the issues. Surveys suggest that 74 percent of Americans don’t want to see the ACA repealed in full. Be a positive resource for colleagues, patients, loved ones, and neighbors who want to learn more. Encourage those who are interested to contact their lawmakers and advocate for the rights of patients, hospitals, and communities.