Patients and physicians can expect (and many hope for) significant upheaval under the new administration. Repeal or piecemeal dismantling of the Affordable Care Act is imminent and the shift toward value-based (as opposed to volume-based) Medicare payments is now uncertain. Plans to sell insurance over state lines, a common theme among GOP Presidential candidates for decades, is still realistically a nonstarter. There is presently no Federal impediment to across-state-lines arrangements. Most states want to regulate insurance products themselves and not relinquish that control to the Federal government. The Affordable Care Act (ACA) actually has some provisions to encourage more regional and national sales of insurance, but they have not proved popular. Within the past several years, a number of states passed laws to allow out-of- state insurance sales and not a single out-of-state insurer took them up on the offer.

Dismantling the ACA will have several implications so it is unlikely to happen quickly:

• Dropping of over 20 million from insurance rolls risks a resurgence of uncompensated care for hospitals/emergency departments and increased healthcare costs for covered and cash-pay patients. Medicaid costs for states will also rise significantly though the Federal government will save by eliminating subsidies.
• Resumption in lifetime limits and pre-existing condition restrictions on health insurance making it more likely for those with costly conditions to lose coverage and for more families becoming bankrupt due to a medical condition. Although the new President implies that he would try to keep the popular pre-existing condition limitations, the insurers are unlikely to play unless they get some quid pro quo. The “individual mandate” is the current payback for insurers reeling in these restrictions. Prior to the ACA, it was not uncommon for patients to be uninsurable at any price if they had any cancer history or history of other high-cost issues including migraines, fibromyalgia, autoimmune disorders, arthritis, cardiovascular disease, even acne, fibrocystic breast changes, skin cancer, or benign polyps could be disqualifying conditions.
• Eliminate the protection of being dropped by your insurer in the midst of a catastrophic illness.
• Increase in health insurance costs for older pre-Medicare patients, which are capped under the ACA not to exceed 30% above the premium for young, healthy patients. Although the new President suggests high risk pools to cover those with costly conditions, those pools are most likely to only impact the extreme high cost patients, not the typical 50-65 yo patient with multiple chronic illnesses.
• Lift the lid on insurance industry profits – under ACA insurance administrative costs are capped at 20% of the premium dollar (25% for individual market). Many individuals and businesses initially received insurance refunds when insurer profits exceeded those caps. Many forget that prior to the ACA, premiums/deductibles/copays for businesses rose far faster than they have risen since. Health care costs pre-ACA rose at more than twice the rate of inflation.
• Elimination of controversial covered contraceptives which will potentially result in a resurgence of unplanned pregnancy and teen pregnancy which is presently the lowest rate ever. Unplanned pregnancy boosts costs associated with poverty, Medicaid/CHIP, food stamps, foster care, etc.
• Elimination of coverage without cost-sharing for evidence-proven preventive care.

The President seems supportive of allowing young adults to stay covered under parent’s plans until age 26 which is unlikely to get any push-back from the insurers. He also appears supportive of expanding use of health savings accounts allowing patients to directly pay primary care physicians with pre-tax dollars. Boosting this free-market model would increase the popularity of direct primary care options including the high-end concierge model.

As a physician, an employer, and a citizen, I will continue to educate our legislators on common sense solutions to this costly and unwieldy system that delivers a poor return for our health dollar investment. Extricating ourselves from the insurance industry has allowed LifeScape to deliver more personalized proactive care and be better advocates for your health. We greatly appreciate the widely varied opinions and intelligent discussions on healthcare we’ve enjoyed with many of you.