Trump lays out principles for ACA replacement


Flexibility and choice were key themes in the health care reform vision President Trump outlined in his first speech to a joint session of Congress on Feb. 28.

Specifically, Americans should be able to “purchase their own coverage through the use of tax credits and expanded health savings accounts, but it must be the plan they want, not the plan forced on them by our government,” Mr. Trump said. They also should be able to purchase insurance across state lines, which “will create a truly competitive national marketplace that will bring costs way down and provide far better care.”

Courtesy whitehouse.gov

President Trump addressed a joint session of Congress on Feb. 28

More broadly, he repeated a campaign talking point of ensuring that those with pre-existing conditions have access to coverage and that there should be a stable transition for those who currently get coverage through the exchanges to whatever will replace the Affordable Care Act.

He also advocated providing more flexibility to states to improve Medicaid but did not provide any specifics on how that would be accomplished.

Finally, Mr. Trump called for “legal reforms that protect patients and doctors from unnecessary costs that drive up the price of insurance and work to bring down the artificially high price of drugs and bring them down immediately,” he said, adding that the Food and Drug Administration needs to slash the time to approval for drugs and other medical treatments.

Some of these concepts were mirrored in a talking-points memo from the House Republican leadership earlier in February.

According to the memo, Republican efforts to repeal and replace the ACA will focus on the following areas:

• Repealing the ACA’s Medicaid expansion and allowing states to choose between block grands or per capita grants for Medicaid funding. States could choose to use those grants and per capita grants to keep expansion.

• Rebranding high-risk pools as “state innovation grants” to provide states with flexibility to design coverage that meets the needs of their populations. States could use the innovation grants to reduce patient out-of-pocket costs, lower the cost of providing care, stabilize the individual and small-group markets, provide access to preventive care, and promote participation in private health care plans.

• Promoting health savings accounts tied to high-deductible plans through increasing maximum contribution limits and other administrative fixes to allow for greater flexibility in their use.

• Replacing ACA premium subsides with refundable flat tax credits. Credit would be age-based, with younger recipients receiving smaller credits and older taxpayers being eligible for more. Tax credits would be available to those who are not eligible to receive coverage through other sources, such as an employer or government program.

Many of these provisions were included in a health reform plan known as A Better Way, which was announced in June 2016 by House Speaker Paul Ryan (R-Wis.).

Like Mr. Trump’s outline to Congress, the GOP talking-points memo was light on specifics, including how the bill will be paid for, how much money will be distributed to states for Medicaid, and how these provisions would alter current insurance coverage rates, which government actuaries project would reach 91.5% by 2025 under current law.

The GOP talking-points memo followed a Feb. 10 discussion draft that included the legislative language required to implement these concepts and allowed insurers to charge higher premiums to people with coverage lapses; repealed a number of taxes imposed on insurers, pharmaceutical companies, and device manufacturers; eliminated many of the ACA’s essential benefits; and ended tax penalties on companies that do not provide coverage to their employees.

This proposal, however, is already running into opposition from House Republicans, with reports stating that blocks of Republicans would not approve of the provisions.

It also could run aground in the Senate, where Sen. Lamar Alexander (R-Tenn.), chairman of the Committee on Health, Education, Labor, and Pensions, has expressed his intent to tackle heath care reform in pieces (public programs, the individual market, and employer market) to avoid getting bogged down in one overarching piece of legislation.

Getting Republicans on the same page is going to be a huge hurdle to get any legislation passed long before it comes down to trying to secure any Democratic votes to help pass any replacement legislation.

As former House Speaker John Boehner told physicians and health care IT leaders at the HIMSS annual conference on Feb. 23, “In the 25 years that I served in the Unites States Congress, Republicans never ever one time agreed on what a health care proposal should look like. Not once. … If you repeal without replace, anything that happens is your fault. You broke it. … If you pass repeal without replace, you’ll never pass replace because they will never ever agree on what the [replacement] bill should be.”

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