Life after Obamacare: Some anxious to see if Trump ends ACA, what happens next

Nov. 12--Wilton Manors health insurance broker Cliff Eserman has a lot of clients with HIV and AIDS who wouldn't have health insurance without the Affordable Care Act, better known as Obamacare.

Following the election of Republican candidate Donald Trump, who promised during his campaign to repeal and replace Obamacare upon taking office in January, "most of my people are very scared," Eserman said this week, "because they have a pre-existing condition."

Before the Affordable Care Act was enacted in 2010 under outgoing President Barack Obama, insurers could deny coverage to people with pre-existing conditions. Clients who have come to rely on their Affordable Care Act plan, and the tax subsidies that make it affordable, are now afraid they'll be denied coverage or won't be able to afford any coverage that will be available, Eserman said.

"In their minds, they're going to be thrown off the ACA. A lot of people think they're being targeted," he said. "They only know the Republicans want to kill it. That's all they know."

Eserman said he tries to reassure clients by telling them, "I don't think the ACA can be repealed on its face." But he admits: "I'm not sure whether or not I'm just blowing smoke."

The truth is that no one, including Republican members of Congress who have been trying to repeal the Affordable Care Act since its enactment, knows what will happen after Trump is inaugurated Jan. 20 and after the next Congress is seated.

In an interview Friday with the Wall Street Journal, Trump repeated his pledge to deal quickly with the ACA, while saying he might be open to retaining the ban on denying coverage to people with pre-existing conditions, and to continue allowing children to stay on their parents' policies until age 26.

Meanwhile, experts say they're telling consumers to continue signing up for 2017 plans during the current enrollment period scheduled to end Jan. 31.

"We're telling people that we're still enrolling for 2017, that we're still moving forward the way we were," said Jodi Ray, who oversees Florida enrollment outreach at the University of South Florida's nonprofit Florida Covering Kids & Families program.

Those enrollments represent a contract between insurance companies, the federal government and roughly 20 million consumers nationwide -- including 1.2 million in Florida and nearly a half-million in the tricounty region -- and it would be highly unlikely for the president or Congress to take any action that would cancel those contracts before they expire at the end of 2017, analysts say.

A more likely scenario, they say, is for Congress and the administration to sunset the most contentious provisions -- among them federal tax subsidies and the requirement that everyone must buy insurance -- as they hammer out a transition plan.

Florida Blue, a Blue Cross Blue Shield company and the only company offering ACA plans in all 67 Florida counties for 2017, issued a statement Friday saying that Trump's promise to repeal and replace Obamacare "could not happen overnight."

"The law has been in place for six years and the impact to the 20 million people who now have health insurance under the ACA must be considered," the statement said.

Florida Blue's mission "to help people and communities achieve better health has not changed and we believe that our goal of providing continued access to quality and affordable health care is one shared by many, including those that will lead and serve in the new administration.

"We intend to work diligently with newly elected federal officials, as well as with our own state legislation, to continue to deliver on our mission."

Repeal of the legislation that made the Affordable Care Act law of the land would require a 60-vote, filibuster-proof majority in the Senate, which Republicans won't have.

In addition, the ACA is too tightly interwoven with the two other major federal health programs, Medicare and Medicaid, to shut down overnight, Eserman said. For example, the federal government negotiated prescription drug cost savings for people in the Medicare Part D coverage gap -- called the "donut hole" -- and used those savings to help fund the ACA. Killing the ACA would also kill those Medicare drug cost savings, he said.

Republicans' likeliest strategy for dismantling its most objectionable provisions would take place through the Congressional budget reconciliation process, said Cynthia Cox, associate director of health reform and private insurance for the Kaiser Family Foundation, a nonprofit, nonpartisan health policy think tank.

Because that process requires just a simple 51-vote majority for passage, it could be used to quickly kill the ACA's federal tax credits, the individual mandate, and Medicaid expansion, which enabled participating states to extend coverage to people too poor to qualify for Obamacare plans. Florida, under Gov. Rick Scott, did not expand Medicaid, leaving nearly 500,000 residents uncovered, according to the foundation.

Use of the reconciliation process to kill those Obamacare cornerstones would essentially kill Obamacare, Cox said. But it wouldn't kill the ACA provision that bars insurance companies from denying coverage to people with pre-existing conditions, which would require a filibuster-proof, 60-vote Republican majority or enough Democrats to cross party lines to get to 60 votes.

That's a problem, experts say, because taking away the requirement that consumers buy health insurance while the pre-existing conditions provision remains in place would saddle insurers with the responsibility to cover the sickest and costliest patients without a guaranteed pool of healthy premium-payers.

And that, Cox said, would send the individual health insurance market, subsidized or not, into a "death spiral" that would end with insurance companies simply pulling out of the individual market altogether.

Rather than taking a guillotine approach to repealing the ACA, Cox expects Congress and the new administration to set a 2018 or 2019 sunset date to buy time to create to create a replacement plan.

Trump's campaign website includes a health care policy paper with some broad pledges.

In addition to removing the health insurance purchase requirement, Trump promised to make health insurance premiums fully tax-deductible; allow insurers to sell products across state lines; fund Medicaid with block grants to states; allow individuals to make tax-free contributions to health savings accounts; require price transparency from health care providers; and remove barriers to markets for drug providers that offer "safe, reliable and cheaper products."

Also, the site says Trump would "review basic options for Medicaid and work with states to ensure that those who want health care coverage can have it."

Indiana offers a glimpse at what might replace the Affordable Care Act, said Mark Cherry, principal analyst with health care industry analyst Decision Resources Group.

Indiana Gov. and Vice President-elect Mike Pence angered liberals and conservatives alike in 2014 by announcing he would accept federal money to expand his state's Medicaid program. Unlike other states, Indiana's program created health savings accounts that enrollees are required to pay into as an added incentive to stay healthy and not overuse benefits.

Pence's program extended Medicaid eligibility to low-income adults up to 138 percent of the federal poverty level, and locked out enrollees above the federal poverty line for six months if they fail to make monthly payments.

The Obama administration approved Pence's Medicaid expansion program in 2015.

"This plan would fit into what Trump is saying about health savings accounts," Cherry said. "And perhaps states could decide whether to keep eligibility to the traditional Medicaid population, or expand it to [people whose incomes are at] 400 percent of the federal poverty level (the current threshold for ACA tax subsidy eligibility), depending on how far they can stretch the block grant."

Jay Wolfson, a senior associate dean of the Morsani College of Medicine at the University of South Florida, called Pence's plan "a bright spot" in the discussion of alternatives to Obamacare.

Wolfson predicts Obamacare will be replaced with something that more closely resembles "any other expense, like a TV or phone," than an entitlement. The next iteration of health insurance, he thinks, won't charge consumers for services they don't use; will cover people with pre-existing conditions through subsidized high-risk pools or catastrophic coverage; and will pay providers based on patient outcomes rather than traditional "fee for service."

It will also build upon cost-savings measures that have evolved under Obamacare, such as narrow coverage networks and increased use of long-distance telemedicine visits, Wolfson said.

During the transition, patients with HIV/AIDS or other serious illnesses will likely lose some of the benefits they've become accustomed to, he said.

"It's going to be a challenging transition for all of us," he said. "As has always been the case in health care, the blunt end of the sword hits the patient first."

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