But within hours of his election, Trump dialed back that pledge, according to The Washington Post. The president-elect said he would keep a clause in the law allowing people up to the age of 26 to get insurance through family policies and would retain a provision that requires insurers to provide policies to people with pre-existing conditions.
Republicans in Congress, who now have a majority in the Senate and House, have also pledged to repeal the 2010 law. In the past four years, they have voted 54 times to repeal it, according to The Washington Post.
The Affordable Care Act guarantees millions of Americans access to health insurance and subsidizes policies. If the law is repealed, 22 million people would lose coverage, according to a report from the BBC. Tens of thousands of those people live in Vermont.
Vermont insured people using a combination of Medicaid expansion and state-level subsidies for commercial insurance, and the state cut the number of people without insurance in half between 2009 and 2014.
By 2014, when the Affordable Care Act marketplaces such as Vermont Health Connect were just starting out, only 23,231 people in Vermont lacked health insurance, according to the administration of Gov. Peter Shumlin, compared with 47,460 in 2009.
Repeal would have a devastating impact on Vermont’s Medicaid population, according to Lawrence Miller, the chief of health care reform for the Shumlin administration. Miller, who did not respond to requests for comment from VTDigger, told Vermont Public Radio that the state has leveraged millions of dollars from the federal government to expand Medicaid and subsidize commercial insurance plans for Vermonters. He said that money would disappear if Obamacare is fully repealed.
An official with the Legislature’s Joint Fiscal Office said the extent of the effect would depend on the details.
“It is impossible for us to comment (on how much money the state could lose if Medicaid expansion is repealed) as we do not know what would be repealed at this point and how a repeal would be structured,” said Stephen Klein, the chief fiscal officer for the JFO.
Medicaid was a $1.7 billion part of the state budget in fiscal year 2015, and the federal government paid 56.5 percent of that. The percentage the feds pay has been declining since 2011 and adding to the Legislature’s annual budget problems.
When Medicaid expansion began in 2014, the number of low-income children enrolled in it went from 60,300 in December 2013 to 67,700 in October 2015, likely in part because of income calculation changes.
Additionally, adult Vermonters enrolled in income-based Medicaid programs (as opposed to disability-based programs) skyrocketed — from about 62,500 in December 2013 to 78,500 in October 2015. The federal government paid up to 90 percent of the cost of enrolling those new adults in Obamacare Medicaid.
Many of the new enrollees qualified because they made more than the old income maximum — 100 percent of the federal poverty level — and less than the new income maximum — 138 percent of the federal poverty level. Most of them previously used either the Vermont Health Access Plan, or VHAP — which was extremely similar to Medicaid — or Catamount Health, a state-created private-public partnership.
If Medicaid expansion were completely repealed, the Vermont Legislature would need to decide whether to create new government programs to replace VHAP and Catamount Health — which the federal government may not agree to chip in for — or take no government action to insure people making between 100 percent and 138 percent of the federal poverty level.
All-payer
The future is also uncertain for the so-called all-payer model, Vermont’s new agreement with the federal government that would pay doctors monthly fees for taking care of patients instead of so-called fee-for-service, which pays for each individual procedure a doctor performs.
The Shumlin administration has said the all-payer agreement with the federal Center for Medicare and Medicaid Innovation allows either the state or federal government to exit the agreement with no financial penalty with 180 days’ notice.
Eric Davis, a retired political science professor from Middlebury College, predicted that a low-level administrator at the U.S. Department of Health and Human Services would be the main person to decide on the future of the all-payer model.
“I’m not sure if they’re going to be interested in continuing with experiments like waivers, and if they are, one possible response that the Trump administration could make, is you can do what you want, but if you expect extra money from Washington to pay for any of it, look someplace else,” Davis said.
Floyd Nease, the spokesperson for the health provider alliance OneCare Vermont and a former majority leader for Democrats in the Statehouse, said Congress will have to do something “that looks like repealing Obamacare” without fully getting rid of it.
Congress has vowed it will get rid of it, he said. “(House Speaker) Paul Ryan has said that. Trump has said that,” Nease said. “So they’ve got to do something that passes some kind of straight face test.”
Al Gobeille, the chair of the Green Mountain Care Board, said last week that the Affordable Care Act is a complex, 2,000-page law that cannot be repealed as simply as he can take the car keys away from his son.
“It’s easy to say ‘repeal,’” Gobeille said. “You then must replace, and replacing is not just being a critic. You have to have a plan. This is complicated, complicated stuff times 20, so it’s not easy to just say, ‘Let’s repeal that.’”
“That’s not a legitimate intellectual position,” he said. “The question becomes, what could they modify about it? What could they alter about it? And what does that small change — what does it mean?”
New programs
The Affordable Care Act, signed in 2010, mandated that all Americans buy health insurance, and it both regulated and subsidized health insurance so people buying through HealthCare.gov or a state exchange would pay only a small percentage of their incomes for health insurance.
The Affordable Care Act also allowed states to extend Medicaid coverage to more low-income people, prevented insurance companies from discriminating against women and against people with chronic diseases, and allowed young adults to use their parents’ health insurance until age 26.
Additionally, the law created the Center for Medicare and Medicaid Innovation, or CMMI, a new office within the U.S. Centers for Medicare and Medicaid Services. That new office negotiated the all-payer model that the Obama and Shumlin administrations signed Oct. 28.
Tom Huebner is the chair of the Vermont Care Organization, the central organization in the all-payer model. He’s also the CEO of Rutland Regional Medical Center and the New England representative to the American Hospital Association.
Huebner said it’s unlikely the Republican leadership will want to get rid of the Center for Medicare and Medicaid Innovation. He cited a federal law known by its acronym, MACRA, which passed Congress in 2015 with broad bipartisan support and puts Medicare on track to pay doctors for the quality of their care, not the quantity of procedures they perform.
“I think this concept of value-based payments they’re going to want to keep, and the generator of value-based payment ideas is CMMI,” Huebner said. “You know, they like to criticize CMMI, until it’s their CMMI, and then they might really love it. And I actually think that’s what’s going to happen.”
Huebner predicted that Republicans might repeal the mandate that everyone buy health insurance and the so-called Cadillac tax that would place an excise tax on health insurance plans like those for teachers and state workers.
Huebner predicted the next things to go would be the health care exchanges and the subsidies those exchanges use to help people afford their insurance. Next would be Medicaid expansion, he said.
Huebner said repealing Medicaid expansion and exchange subsidies is a “loss of money” that “would be a very significant loss to the state. And that part I think is a significant risk.”
