Today’s blog post comes from Pat Baker, President and CEO of the Connecticut Health Foundation on the post-election health care landscape.
The recent election has the potential of having a significant impact on healthcare and health spending. The language occupying the news most often centers on “repeal and replace” the Affordable Care Act (ACA). The reality is that the impact is even greater as discussions include the ACA, Medicaid, and Medicare. For those of you familiar with the Speaker of the House, Paul Ryan’s past budget proposals, this is not surprising. Congressman Ryan’s budget proposes to block grant Medicaid moving it from an entitlement program and privatize Medicare as well as repeal of the ACA. If these changes take place we are talking about fundamental shifts in the country’s approach to health care spending.
Uncertainty is the word of the day. The ACA is a very complicated piece of legislation with many provisions and changes in any one provision has significant ramifications on others. In President Elect Trump’s 60-Minute interview, he said he wanted to preserve the requirement to provide coverage for those with a pre-existing conditions. This may be true, but the economic realities of preserving that coverage affects the ACA on multiple levels. It is estimated that 130 million people in the United States have pre-existing conditions and the reason there is an individual mandate in the ACA is to share the risk with all; otherwise, the costs are prohibitive. One could say you are keeping this requirement, but without the mandate, premiums would be too costly for most to secure coverage.
The Ryan budget proposes to block grant Medicaid. This would eliminate Medicaid as an entitlement program for which recipients qualify based upon income to a global capped budget in which states determine how they utilize these dollars. While it provides greater flexibility, it does not allow accommodation for jumps in enrollment during times of recession, new treatment options, or emerging health crisis. The other question many ask is how will they calculate the block grant’s base? Is it based on pre-ACA or post? To date 204,000 people in Connecticut have gained Medicaid coverage due to the expansion of Medicaid through the ACA with the federal government picking up 95% of the cost. Is the block grant going to look at the expenditures to date including the 204,000 or revert back to a time before they were allowed to gain coverage?
The budget also proposes to privatize Medicare, changing the bargain that the original legislation offered to senior citizens. It would no longer be an entitlement program.
We can only speculate on what is to come. Most experts believe that it will take time to repeal the ACA and that any real change won’t likely be seen until 2018. In the shorter term, there is a budget reconciliation bill that will need to be passed in December 2016 which provides an opportunity to make budget changes such as the elimination of subsidies for those covered on the health care exchanges, block granting Medicaid, elimination of the individual mandate, just to name a few. The peril of this process is that it allows passage to occur by a simple majority so the opposition party cannot stop a unified party in making these changes.
All of this will require our foundation to stay alert and nimble while staying true to its mission. As we face these turbulent times, please remember that the need for coverage, connection to care, health delivery transformation, and controlling cost are still very much present. Health care in this country still is not value based, we still face significant racial and ethnic health disparities, so the work must continue. While the “how” may change, the “what” remains steady.
Even as I write this, I remain grateful that we are in this together. Take care, and have a wonderful holiday.