The document discusses potential reforms to the US healthcare system following the 2016 election. It outlines President Trump's platform of repealing the Affordable Care Act and replacing it with a patient-centered system focused on choice, quality, and affordability. Issues cited with the ACA include rising premiums, insurers exiting markets, and high deductibles. The platform proposes solutions like allowing cross-state insurance sales, health savings accounts, and granting states more flexibility in Medicaid. Repealing the ACA faces challenges, but elements may survive through budget reconciliation or remain due to popularity.

1. Mark C. Smith HMS, MBA, PMP
November 12th 2016
Healthcare Reform
Post 2016 US Election
Shades of Repeal
Illustration by Matthew E. Smith

2. Platform Vision
• Repeal and replace The Affordable Care Act (ACA) with Health Savings
Accounts (HSAs).
• Work with congress to create a patient-centered health care system that
promotes choice, quality, and affordability.
• Work with states to establish high-risk pools to ensure access to coverage for
individuals who have not maintained continuous coverage.
• Allow people to purchase insurance across state lines, in all 50 states,
creating a dynamic market.
• Maximize flexibility for states via block grants so that local leaders can
design innovative Medicaid programs that will better serve their low-income
citizens.
https://www.donaldjtrump.com/policies/health-care/

3. Affordable Care Act: Issues Cited
Affordability
• Increasing Premiums, National average 25% increase - [Kaiser Family Foundation] [ACA Signups], [Health
Insurance], [Miami Herald], [Health Insurance]
Why?
• Two thirds of exchanges lost 2.2 billion in 2014 - Mercatus Center
• Losses caused insurers to exit markets and consolidation to achieve greater scale, reduced completion and
choice, compounded by limitations cross state coverage resulting in 19% of Americans having a single choice in
coverage. [New York Times, Aug. 19, 2016], [Kaiser Family Foundation, Aug. 28, 2016], [McKinsey on Healthcare,
Aug. 18, 2016]
• High deductibles, ½ of the exchange plans $3,000 or more [The New York Times, Nov. 14, 2015] , expected to
continue to increase in 2017 [Investors Business Daily, May 13, 2016]
Dynamics:
• Due to cost increases enrolment is down, with the majority of participants through Medicaid and CHIP, by 2026 ¼
of population will be on Medicaid. [Congressional Budget Office, March 2016] Lack of providers due to market
forces [Department of Health and Human Services, Office of the Inspector General, Dec. 2014]
• Medicaid beneficiary coverage decline, increase ED, poor outcomes due to lack of prevention. [“How to Fix
Medicaid,” National Affairs, 2014]
• Contributing increases in costs, impact hiring, reduced full time employees[The New York Times, Feb. 20, 2014]
https://assets.donaldjtrump.com/HCReformPaper.pdf

4. Platform Proposed Solutions
• Goals: Broaden healthcare access, make healthcare more affordable, and improve the
quality of the care available to all Americans.
• Actions: Implement policies and reforms aligned to free market principles
• Expected Outcomes:
• Legislation to repeal Affordable Care Act, not to require individuals to purchase insurance.
• Allow sale of health insurance across state lines (benefit to private insurers)
• Health Insurance Fully Deductible
• Individual Pre Tax HSAs, compound carry over savings
• Price transparency or all providers
• State grant’s for Medicaid administration of state populations
• Remove barriers to entry: Drugs Manufacturers and imports
https://assets.donaldjtrump.com/HCReformPaper.pdf

5. Triple Aim and MACRA Impact
It Depends:
1. Patient Experience –private insurance vs. government program
2. Population Health – Insurance, provider, and state collaboration
3. Cost of Care – MACRA vs. Free Market
MACRA (Medicare Access and Chip Reauthorization Act)
Title 1 “incentives for accountability”
• Consider impact of regulation, funding, and administration in terms of incentives and
penalties going forward.
http://www.ihi.org/engage/initiatives/tripleaim/pages/default.aspx

6. Shades of “repeal”
• It would take 60 votes in the Senate, of which Republicans hold 51 seats and lack consensus, not a likely path.
• Budget reconciliation is more likely:
• Eliminated income based subsidies thus reducing affordability
• Cut Medicaid expansion funding to 31 states and HR 3762
• Deadline to dismantle is May or June of 2017, before plan submission requirements for 2018, and subsidies
expire in 2019.
• Eliminate or reduce provisions such as the Cadillac tax set to kick in in 2020
• Insurers would not be able to deny coverage without a complete repeal – Trump Confirmed to Keep, WSJ
11/12
• Some elements expected to survive repeal, due to popularity
• Young adults able to stay on parents health plans – Trump Confirmed to Keep, WSJ 11/12
• People with health problems able to buy insurance but not pay more
• Medicaid expansion with varied federal financing
• Legal challenges with canceling 2017 enrolment contracts.
http://www.reuters.com/article/us-usa-election-obamacare-analysis-idUSKBN135171
http://www.forbes.com/sites/theapothecary/2016/11/09/under-president-trump-repealing-replacing-obamacare-will-be-harder-than-it-
looks/#330c655d7d24
http://www.wsj.com/articles/donald-trump-willing-to-keep-parts-of-health-law-1478895339