The only certainty about the future of Obamacare right now is this: Everything is uncertain.
In the 72 hours following his election, Donald Trump has made significant new statements on the Affordable Care Act. He campaigned on repealing Obamacare. But last Friday, he told the Wall Street Journal that he wants to keep the ban on preexisting conditions and continue to allow young adults to enroll in their parents’ insurance plans.
Caitlin Owens of Morning Consult reports that congressional Republicans want to save Medicaid expansion — but then House Speaker Paul Ryan told CNN Sunday that he wanted to replace Medicaid expansion with tax credits for private insurance.
Washington observers expected Republicans to pursue repeal before replace. That was, however, before Trump told 60 Minutes Sunday that he wants both to happen in tandem.
The list of opposing positions goes on and on. We are in a moment where there is lots of speculation about a dizzying array of possibilities of what might happen next. The problem is all the signals point in different directions.
Part of this has to do with Trump himself, who has held a variety of views on health care — at one point, he supported a single-payer health care system. But part of this just has to do with the act of legislating itself, which is messy and requires significant compromise.
When President Barack Obama came into office in 2008, he had campaigned against an individual mandate. He supported a public option. But he ran into stubborn realities of both policy and politics that meant the law he signed didn’t align with those initial positions.
We are at the beginning of a long and difficult legislative process, and right now we don’t know how exactly it will end.
President-elect Trump’s views on health policy are constantly evolving
In 2000, Trump wrote a book called The America We Deserve. It included this passage on health care:
We must have universal healthcare … I'm a conservative on most issues but a liberal on this one. We should not hear so many stories of families ruined by healthcare expenses…
Doctors might be paid less than they are now, as is the case in Canada, but they would be able to treat more patients because of the reduction in their paperwork
The Canadian plan also helps Canadians live longer and healthier than Americans. There are fewer medical lawsuits, less loss of labor to sickness, and lower costs to companies paying for the medical care of their employees. If the program were in place in Massachusetts in 1999 it would have reduced administrative costs by $2.5 million. We need, as a nation, to reexamine the single-payer plan, as many individual states are doing.
And recently, he again complimented single-payer health care systems.
“As far as single-payer, it works in Canada,” Trump said during the first Republican debate, responding to a question about his stance in 2000. “It works incredibly well in Scotland. It could have worked in a different age, which is the age you’re talking about here.”
During the campaign, Trump also stated a preference for a “universal health care plan,” which was at odds with his own policy proposal.
"I am going to take care of everybody," Trump told 60 Minutes in an interview last fall, during the primaries. "I don’t care if it costs me votes or not. Everybody’s going to be taken care of much better than they’re taken care of now."
The plan that Trump released this past March did not live up to that promise. Instead, the Committee for a Responsible Federal Budget estimated that it would cause 21 million people to lose insurance coverage.
But Trump’s views on Obamacare have changed even since he won election. In the past few days, he’s said Congress should repeal and replace Obamacare at the same time, rather than one after the other — and he’s said there are pieces of the law he wants to keep.
Trump told the Wall Street Journal that he changed his mind on these provisions after meeting with President Obama, who pressed the case for preserving key parts of his health law.
New York Times political reporter Maggie Haberman reads this as an important example of how Trump makes decisions, often pivoting based on his most recent conversation.
A key piece of understanding Trump? He is often swayed by whoever he last talked to https://t.co/8IuhEnvXUT— Maggie Haberman (@maggieNYT) November 11, 2016
Given all the change we’ve seen from a candidate Trump, and now a President-elect Trump, it seems fair to expect that the views he articulates now may not be the views he has in a few weeks or a few months. Some of that might reflect a legitimate change of mind. And some of it might reflect the hard truth of health reform that Obama encountered: Passing the health reform package you want is really, really hard.
Republicans have struggled to coalesce around an Obamacare replacement plan
It isn’t just up to President-elect Trump what changes about Obamacare: He’s also working with hundreds of Republican legislators who have their own ideas about what the future of health policy in America should look like.
There are more than half a dozen Obamacare replacement plans that Republicans have come up with in recent years. Harvard University’s John McDonough summarized them in 2015 for the academic journal Health Affairs.
The reason there are so many plans is simple: Republicans have not been able to coalesce around one of them. There are still significant differences in opinion over the right way to move forward.
McDonough analyzed the plans last September. He finds that five of them repeal the Affordable Care Act entirely, and three retain some portion of the original law while amending it significantly. Seven plans eliminate the health law’s Medicaid expansion, but one plan does not. Some plans repeal Obamacare’s changes to how we pay for Medicare — a portion of the law pretty separate from the coverage expansion — and others leave them intact.
There are significant differences between the number of people these plans would cover too.
Avik Roy, president of the Foundation for Research on Equal Opportunity, worked with economists to model the effects of a few of the proposals. They estimate that one prominent repeal plan, the Patient CARE Act, would only reduce coverage by 3 million people compared with the Affordable Care Act — and that Speaker Paul Ryan’s proposal would reduce coverage by 2 million. Roy estimates that his own proposal would increase the number of Americans insured by 9 million. (Although the type of insurance they would receive would be quite different from what is required under the ACA. You can read more about that in Roy’s plan.)
And then there is the estimate from the Congressional Budget Office that if Obamacare is repealed and not replaced at all, 22 million Americans will lose health insurance coverage.
The difference between 22 million Americans losing coverage and 9 million people gaining insurance is huge. But that’s the space that exists, right now, in the debate over Obamacare’s future. We might end up at one end; we might end up in the middle. I personally think it makes sense to take Republican legislators’ claims that they plan to pass a replacement plan in good faith, watch what happens next, and report on the repercussions, both positive and negative.
Uncertainty is bad for the 20 million Americans who rely on Obamacare
There is very real, negative fallout from this uncertainty around Obamacare’s future. Consider the case of Randi Goldberg, a 33-year-old woman in St. Louis who uses the health care marketplace. She’s had her plan since this summer, when she moved to St. Louis and took a job at a rock climbing gym that didn’t provide health insurance.
Goldberg had a lump on her breast that she’d been ignoring. But after getting coverage, she decided to go to the doctor and get it checked out. It turned out Goldberg had breast cancer, and she immediately went into treatment. In September she had a unilateral mastectomy. She had four lymph nodes removed during that surgery, and three showed signs of cancer, so she had additional surgery and is currently in chemotherapy and radiation.
Goldberg doesn’t really know how long her treatment will last at this point. She thinks the radiation and chemotherapy will be done by the end of 2017. But there are other things that might take longer, like if she does hormone therapy after finishing cancer treatment. She needs insurance to help manage a new condition she developed, lymphedema, from the removal of her lymph nodes.
Before Tuesday night, the timeline didn’t matter to Goldberg — she planned to stay on Obamacare and finish her treatment. But now she doesn’t know whether Obamacare will be around, or what might replace it. And it feels like her treatment is, all of a sudden, on a timeline — she really wants to get as much done as she can this year and next, when she has the certainty of coverage.
“Before Tuesday I was mostly focused on getting better,” she says. “But now I feel like there is this timeline, like I really need to guarantee that there is no delay in my treatment because who knows what will happen next.”
Goldberg now has to make decisions in a very uncertain time. She wants to go back to school, to get a degree in behavioral therapy to work with kids with autism. But now she doesn’t know if she should apply to school.
The eventual Republican replacement plan might help Goldberg. Or it might leave her in the lurch. It is far, far too early to jump to conclusions about what the insurance market will look like a few years from now.
But make no mistake: Just introducing a new uncertainty about the future of health insurance is already causing significant disruption for Goldberg and many other Obamacare enrollees. She is making different decisions about her life than she would have a week ago — and finding her options more limited just because