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Repeal, Replace, Repeat
Health Reform During the Trump Administration
Cedric Dark, MD, MPH
@RealCedricDark
© 20th Century Fox
A Tragic Comedy
• The Campaign
• The Executive Order
• The House
• The Senate
• A Surprise Victory
CAMPAIGN PROMISES
Campaign Promises
• Repeal and replace Obamacare with HSAs
• Block grant for Medicaid
• Insurance across state lines
• Full deductions for health insurance
• Importing drugs from overseas
• Price transparency for providers
THE EXECUTIVE ORDER
Day 1: The Executive Order
The 3-Legged Stool
Charles Gaba / ACAsignups.net
Day 7: TV Sabotage
Day 10: PhRMA bros
Day 38: Insurance Bros
The First 100 Days
The Honeymoon is Over
THE HOUSE
American Health Care Act
• $800B+ out of Medicaid
• $276B+ out of ACA subsidies
• Alter the subsidy formula
• Eliminate employer and individual mandate
• 30% surcharge
• 5:1 Age bracket
• Repeal ACA taxes
• Repeal MLR; Loosen EHBs
May 4, 2017
Day 104:
Mission Accomplished?
THE SENATE
Senātus Populusque Rōmānus
Better Care
Reconciliation Act
• $772 billion out of Medicaid
• $424 billion out of ACA subsidies & CSRs
• Alter the subsidy formula
• Eliminate employer and individual mandate
• 6 month delay
• 5:1 age bracket
• Repeal ACA taxes
• Repeal MLR; Loosen EHBs
Obamacare Repeal
Reconciliation Act
• Essentially considered “straight repeal” of ACA
• Eliminate ACA mandates
• Eliminate ACA taxes
• Eliminate ACA subsidies
• Keep insurance protections for patients
Health Care Freedom Act
• Termed “Skinny Repeal”
• Repeal individual mandate
• Delay employer mandate to 2025
The people said: “No”
Stone Cold McCain
Concession Speech
The Storm Passes
A SURPRISE VICTORY
The Holy Grail
Freedom &
$338B in your pocket
Essentially Repealed
• “We have essentially repealed Obamacare”
Promises Kept?
• Repeal and replace Obamacare with HSAs
• Block grant for Medicaid
• Insurance across state lines
• Full deductions for health insurance
• Importing drugs from overseas
• Price transparency for providers
WHAT’S NEXT?
What’s Next?
• CHIP Funded for 10 years
• Medicaid Work Requirements
• Kentucky, Indiana, Missouri
What’s Next?
• Medicaid Expansion?
• Virginia
• Utah & Idaho
• More attempts at repeal?
• Trump’s budget: a Cassidy-Graham plan
Graham-Cassidy
• Eliminate employer and individual mandate
• Repeal premium and cost sharing subsidies
• Repeal Medicaid expansion in 2 phases
• Replace with block grants vs per capita caps
• Within block grant EHBs other other insurance reforms
don’t apply
What’s Next?
Other health care issues?
What’s in store for Texas?
November 2018
© The Houston Chronicle
Repeal Replace Repeat

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Repeal Replace Repeat

Editor's Notes

  1. January 21, 2016: Trump’s order states that federal agencies can grant waivers, exemptions and delays of “Obamacare” provisions that would impose costs on states or individuals. That language appears to be aimed squarely at undoing the law’s unpopular requirement that individuals carry health insurance or face fines http://www.pbs.org/newshour/rundown/trump-executive-order-affordable-care-act/
  2. January 27, 2017: Trump administration wanted to cut ACA TV ads; backtracked when some all already been paid for by the Obama administration. Wound up spending about 10% of the prior year.
  3. Trump renegs on drug price negotiation in Medicare promise
  4. Tweets: Great meeting with CEOs of leading U.S. health insurance companies who provide great healthcare to the American people.
  5. Political Honeymoon Period.
  6. Republicans in the House of Representatives passed what they said was their plan to repeal and replace Obamacare, after several fits and starts, sending the measure to the Senate, where it is expected to be significantly revised. The bill passed the House in a narrow 217-213 vote. All Democrats opposed the bill.
  7. $800B+ out of Medicaid $276B+ out of ACA subsidies (alter the formula) Eliminate employer and individual mandate Loosen EHBs 5:1 Age bracket Repeal ACA taxes Repeal MLR
  8. The ancient Romans believed all authority came from the people.
  9. Repeals ACA mandates, taxes, subsidies. Keeps the insurance protections.
  10. Skinny Repeal: Individual Mandate & Employer Mandate McCain gave it the “Thumbs Down”
  11. https://www.youtube.com/watch?v=Qz1XKVvHroo
  12. The Tax Bill
  13. CBO and the JCT estimate that, by itself, repealing the mandate would reduce federal deficits by about $338 billion over the 2018–2027 period and increase the number of uninsured people by 4 million in 2019 and 13 million in 2027
  14. CBO and the JCT estimate that, by itself, repealing the mandate would reduce federal deficits by about $338 billion over the 2018–2027 period and increase the number of uninsured people by 4 million in 2019 and 13 million in 2027.
  15. Same old nothing Ballot Initiatives – not possible in Texas Change to the Legislature and Governor to expand Waivers - alternative ways to close the Medicaid Gap
  16. Both Governor Abbott and Ted Cruz are up for re-election. Will this be a referendum on health care reform? Other other issues?