From Medicare to Obamacare to . . . Which way now for healthcare?

Some are just now recovering from the shock of November 8 and the election of Donald Trump, while still others remain at some stage of denial, and fans of Mr. Trump await the dismantling of the Affordable Care Act, Obamacare. The President-elect’s apparent choice of Dr. Tom Price, himself a M.D., as Secretary of Health and Human Services, would seem to send a very unambiguous signal of the likely demise of Obamacare as Dr. Price was among the more vociferous critics of the Act.

But just as it is something of a task to put toothpaste back into its tube, dismantling a piece of legislation and the resulting program in which millions of Americans have enrolled, many of whom had had no insurance previously, is something of a challenge for even the most implacable foe. Moreover, physicians, insurance companies, hospitals, and employers have invested heavily in adapting to the requirements of Obamacare. Some – especially insurers – will be relieved at the program’s demise. Others, including hospitals and physicians, have been moving away from the traditional fee-for-service care model and will now have to wait for what, if anything, replaces Obamacare.

Truth is no one yet has a clear idea of what would replace ACA. And this ambiguity pushes back through the pipeline through which health-care professionals prepare and embark in their respective practices. While it was pretty clear that primary-care physicians would play a (some say the) pivotal role in distributing patients across the various medical specialties and types of health facilities, that could remain the case or change in any number of ways. Yet the production of primary-care physicians has never met the need or demand, so finding ways to increase the pipeline’s numbers remains enigmatic.

Uncertainty is heightened by President-elect Trump’s expression of support for two features of Obamacare: elimination of previous conditions as a consideration for coverage ad extension of coverage for young people beyond age 23. The former was deemed essential since persons without coverage were often the ones who relied on the most-expensive form of health care, the emergency room of hospitals and passed the costs along to the hospital as indigent care. In order to “bend downward” the otherwise upward trend of health-care costs, the pool of those covered had to include such persons, regardless of their prior conditions.

Extending coverage to young people brought into the pool a group who made fewer and lower-cost claims for health care and thus offset the costs of universal or at least near-universal coverage.

Retention of the former would, in effect, preserve Obamacare, so it is difficult to discern how plans to dismantle the program would actually prove effective.

Maintaining young people’s coverage for a longer time was both a pragmatic step and a way to finance the overall system, so eliminating that would remove the means for financing a replacement.

In short, Trump’s new-found appreciation of those two particular elements of Obamacare makes it difficult to see how the program would be eliminated.

But the contrast between Mr. Trump’s views and those of most Republicans in Congress is such that it remains very uncertain what will actually emerge as legislation.

Forecasters and pundits who saw their confident forecasts exploded by the election of Donald Trump may do well to absent themselves from the art or science of predicting what the new administration and Congress will do in the weeks and months to come. For now, uncertainty reigns and much of what had been expected and, in some cases, anticipated remains shrouded.


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