The second Trump presidency could mean big changes for health insurance in Colorado

For months while on the campaign trail, Republican leaders — including President-elect Donald Trump — have been talking about making big changes to the U.S. health insurance system.

It's just not clear what those changes will be or how they would impact Colorado.

Declaring that "Obamacare sucks," Trump has vowed to replace the Affordable Care Act, but he has also at other times expressed openness to keeping it. (The 14-year-old law is, of course, also known as Obamacare, given that it was passed during the Barack Obama administration.) Asked at a debate what he plans to do, Trump said only that he has "concepts of a plan."

House Speaker Mike Johnson has pledged to get rid of the Affordable Care Act without offering specifics, other than to promise "massive reform to make this work."

The Affordable Care Act has become deeply entwined in the health care policy of Colorado and other states, meaning that repealing it or substantially rewiring it will result in big changes. But Colorado will also have a say in how those changes hit the state.

Here's an overview of what it might look like if the ACA were repealed.

Many of the Affordable Care Act's coverage protections would remain

Some of the ACA's most popular provisions are its insurance protections.

Under the law, you can't be denied health coverage because of pre-existing conditions, and you can't be charged more based on your health history. The ACA also requires insurers to provide a minimum level of coverage — the "essential health benefits" — so people don't have to buy additional policies to cover, say, maternity care. (Prior to the ACA, just 12% of plans available to people who shop for insurance on their own offered maternity benefits. Most employer-sponsored plans offered maternity coverage.)

If the ACA were to be repealed, though, many of these protections would likely remain in Colorado — at least for some people. That's because Colorado lawmakers years ago aligned state health insurance rules with those in the Affordable Care Act.

So, state law also prohibits insurers from denying coverage based on pre-existing conditions or charging more based on medical history. Annual and lifetime caps on benefits are also not allowed under Colorado law.

Protections for the essential health benefits are a little less clear because the state law that guarantees them refers to the text of the ACA to define what the benefits are.

"It would present a challenge because then we would be referring to a definition of essential health benefits that would no longer exist," said Adam Fox, the deputy director of the Colorado Consumer Health Initiative.

Fox said he and his colleagues are going through state law now to find potential gaps like this in the state's protections. Those could come up for fixes during next year's legislative session.

Another important point: These protections only cover plans subject to state law. Not all health insurance plans are, such as so-called self-funded employer plans.

Insurance subsidies could go away

People who buy plans on their own currently benefit from advance tax credits to help them pay for their insurance premiums, provided they don't make too much to qualify. About 80% of people who shop for coverage on Connect for Health Colorado this year will be eligible for the subsidies, the state estimates.

And those subsidies can really take the sting out of insurance prices. About 77% of people eligible for subsidies will be able to find a plan on Connect for Health with an after-subsidy premium of less than $100 per month, the state says.

Those subsidies are a function of the Affordable Care Act, meaning they will go away if the law is repealed — as will certain subsidies available to people with especially low incomes that help pay other out-of-pocket costs like deductibles or copays.

Even if the ACA isn't repealed, some portion of the subsidies could still go away. Enhanced subsidies passed during the COVID pandemic are set to expire at the end of 2025 unless Congress reauthorizes them.

Fox, with the Colorado Consumer Health Initiative, said these funding issues show how changes at the federal level could affect people in Colorado even if the protections in their coverage remain.

"The challenge is, if those programs are attacked at the federal level, the funding that allows those programs to work and keep coverage affordable is fundamentally under threat," he said.

Insurance could become more expensive for other reasons

There's one other way insurance in Colorado could become more expensive, and it involves a complicated state-federal program: Reinsurance.

The program uses a pool of government funding to help insurance carriers in the individual market pay their highest-cost claims, allowing those companies to lower rates for everybody.

This has been hugely successful in Colorado in reducing the prices that people pay for their insurance. (The program only impacts insurance bought by people on the open market, without help from an employer. So its benefit doesn't extend to people with plans through work.)

Though prices have gone up in recent years, the state estimates that reinsurance will save Coloradans nearly a half billion dollars this year compared to what they would have paid without it.

But much of the money for the reinsurance program comes from the federal government via a provision of the ACA. So ending the ACA would slash money the state has available to fund the program.

A number of states have adopted reinsurance programs over the years to lower prices, meaning policies that hurt reinsurance could see broad opposition.

"There are a good number of blue and red and purple states that now have reinsurance programs," Fox said. "That's another area where there may be a lot of pushback from insurance companies and state governments."

State regulators would likely fight back

If some of this feels familiar, it's because we've been here before, the last time Trump was president with a Republican-controlled Congress behind him.

Then, after multiple attempts to repeal and replace the ACA, Trump and his Republican allies switched to plan B: expanded access to short-term insurance plans.

Such plans are not governed at the federal level by ACA rules, so they function more like pre-ACA plans. The idea was that by allowing people to stay on short-term plans longer, you could create a kind of non-ACA shadow insurance market.

But Colorado Insurance Commissioner Michael Conway blocked that by issuing a rule that short-term plans in Colorado have to abide by the same rules as ACA plans.

Expect the same kind of regulatory warfare this time around.

"We cannot go back to a world where people are discriminated against simply because they've been sick before and they have a pre-existing condition," Conway said in a statement Thursday. "While we have many of the protections of the ACA in Colorado law, repealing the ACA would have a devastating impact on access to health care and the pocket books of Coloradans, as well as the state's economy."

He said it was too soon to talk about specific actions the state may take.

Fox said this debate highlights the partisan divide on health care coverage. Republicans generally want fewer regulations and for plans to work more like they did in the pre-ACA days, when people were able to buy slimmer plans that were often cheaper.

The cost of those cheaper plans, though, was that people who needed health care shouldered an extraordinary burden. Insurance prices could be prohibitive for older people or those with pre-existing conditions. Carriers could drop coverage for people who cost too much or refuse to issue a plan to someone with serious medical needs.

"Those types of coverage don't provide the same level of consumer protection, and they end up distorting the rest of the insurance market," Fox said. "The former health insurance market was not equitable. It discriminated against people."

The Medicaid expansion could be at risk

The ACA allows states to expand Medicaid eligibility with a sweet deal: For those people eligible for Medicaid via the expansion, the federal government will pay 90% of the costs. Normally, Medicaid is an even 50/50 split for the state and the feds.

Colorado was one of the early states to take up the expansion, which extends Medicaid coverage to people making just above the poverty line. As of last summer, more than 600,000 people were covered under the Medicaid expansion in Colorado, though that number has likely decreased as the state ramped up eligibility renewals following the end of pandemic-era federal rules.

The last time Trump was in the Oval Office, Congressional Republicans proposed a plan that would have phased out the expansion and/or left it up to the state to pick up more of the cost. According to an estimate by the Colorado Health Institute in 2017, if Colorado kept the expansion but reverted to a 50/50 cost split for those covered by it, the state would be on the hook for an extra $800 million a year.

That's almost certainly a nonstarter in a state budget that is already struggling to afford its Medicaid program.

Fox said other changes are also possible to Medicaid funding during the next Trump administration. For instance, the federal government could try to switch to a "block grant" system, where states are given a limited amount of money to run the program, regardless of the amount of care it wants to cover.

That would put states in a budget bind: Cut Medicaid or cut other parts of the budget to sustain Medicaid?

"That ultimately has an impact on state budgets, state policies and state programs," Fox said.

If changes to Medicaid result in more people going without coverage of any kind, hospitals and clinics could ultimately suffer from higher rates of care that they aren't getting paid for.

Research has found that Medicaid expansion, in particular, led to fewer hospital closures and that rural hospitals have struggled most in states that did not expand Medicaid.

Public support for the ACA is actually pretty strong

One thing that makes an ACA repeal even more challenging now is that polls show people generally like it — even more so than during Trump's first term.

"The ACA has only grown in popularity since those repeal fights in 2017, 2018," Fox said.

The latest KFF tracking poll shows the ACA this year hitting its all-time high for favorability, with 62% of adults saying they hold a favorable view of the law. A poll from the Democratic-leaning firm Global Strategy Group found similar numbers.

A Morning Consult poll taken this month found that 55% of voters are in favor of keeping the ACA as is or expanding it, compared with 31% who want to see it repealed in whole or part. That's stronger support than the law had in 2017 — and even Republicans are less in favor of repealing the law, 54% in favor this year compared with 76% in favor in 2017.