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President-elect Donald Trump took aim at the Affordable Care Act on the campaign trail, a platform that appears to be consistent with his pick for health and human services secretary, Tom Price, a Republican U.S. House member from Georgia. But what do we really know about what’s in store for health policy during the Trump administration? And how does it align with what Americans want? We brought together FiveThirtyEight reporters and Larry Levitt, senior vice president for special initiatives at the Kaiser Family Foundation, which researches health care policy, to talk about where the U.S. stands and where it may be going. The conversation has been lightly edited.
Blythe (Blythe Terrell, senior editor for science): So we’ve already had a flurry of news (and speculation) about what a Trump administration will mean for health care. I’ve had these three areas on my mind: 1. Public opinion. If Trump wanted to please the most Americans on health care, what would he change? 2. What does the selection of Tom Price for health and human services secretary tell us? 3. What do we know about what Trump wants to do? What are the big outstanding questions and things to watch?
Let’s start with the first: What are Americans thinking?
Larry (Larry Levitt, senior vice president for special initiatives at the Kaiser Family Foundation): We at Kaiser just did a poll of what Americans think about health care. The public is as divided as ever on the Affordable Care Act. But, interestingly, somewhat fewer people want to repeal the law than before the election.
Anna (Anna Maria Barry-Jester, public health writer): Right, and as we’ve written numerous times (and Kaiser has been polling on this for a while), the law has been politically divisive and very partisan. But many of the law’s provisions are not; there’s pretty widespread support for many components of the law.
Harry (Harry Enten, senior political writer): My understanding is that fewer people than ever want it repealed — or at least for a long time.
Larry: That’s right. Fewer people want it repealed. And all of the major provisions of the law get strong support from the public. The one thing that people really don’t like is the individual mandate, which requires most Americans to have health insurance. So people like all the good stuff in the ACA, but not the uncomfortable thing that makes the good stuff work.
Harry: Right, you can’t have the ACA work without the mandate. It’s like saying, “I want all the bridges and roads without the taxes to fund them.”
Larry: The ACA requires insurance companies to accept everyone, including people with pre-existing conditions. That only works if you get healthy people to sign up as well to balance things out. The individual mandate is the stick to do that. There’s also a carrot — premium subsidies for low- and modest-income people.
Anna: In the most recent Kaiser tracking poll, out Thursday, only 35 percent say they have a favorable opinion of the individual mandate.
Harry: And to be clear, it has always been this way, with the mandate being unpopular. I remember writing about this back in 2013. It is the same story. Here’s Kaiser’s polling from 2014:
Blythe: So do they want to keep it? Or they want parts of it repealed but not all of it?
Larry: In the new poll, 26 percent of people want to repeal the ACA, and an additional 17 percent want to scale it back. Among the people who want to repeal the law, most want it replaced with something else.
Blythe: OK, so people hate the mandate. What do they like?
Anna: They really like a lot of things, according to this poll. Allowing young adults to stay on their parents’ insurance plans until age 26 has been popular all along. But it looks like many other provisions are gaining popularity.
Larry: People also like providing premium subsidies to low- and middle-income people, letting states expand Medicaid, and requiring insurers to accept people with pre-existing conditions.
Here’s the new polling:
Blythe: I used to live in a ski town, and that provision letting people stay on their parents’ plan was a game changer! (Also, young people in ski towns seem to get hurt a lot.)
Larry: Trump has said he wants to keep the provision for coverage of young adults up to age 26 and coverage for people with pre-existing conditions. The first one is pretty easy. The second one is really hard.
Anna: It seems to me there’s kind of a theme to what is most popular. People like the things that improve individual coverage. They don’t like being told what to do, though. So things like requiring businesses to provide insurance and the individual mandate are less popular.
Larry: Anna is right — people like benefits provided by the government, but not requirements that make them do things. Paying for the benefits (i.e., taxes!) is generally pretty controversial too.
Blythe: That brings us to the second question: What does Trump’s pick for health and human services secretary, Tom Price, tell us about Trump’s policy and what he might want to change?
Anna: So much and so little, Blythe!
Larry: Tom Price has been at the center of the debate to repeal and replace the ACA, so his nomination as HHS secretary suggests that the Trump administration is very serious about repealing the law. Price, as a member of Congress, has introduced a detailed bill to replace the ACA.
Harry: From a political angle, most regard Price as a “serious” pick — that is, a wonk. Also a “replace” not just a “repeal” guy, as Larry has said.
Anna: Right. Price has not only been one of the most vocal opponents of the ACA, but he also has one of the most well-thought-out and ready-to-go pieces of legislation to replace it, so in that sense, it tells us a lot. On the other hand, there isn’t Republican consensus on how to replace the ACA. (Nor is there an easy political path to repeal.)
Larry: Importantly, Price is chairman of the House Budget Committee. That’s important because Republicans will probably have to use budget maneuvers to pass an ACA repeal bill without facing a filibuster in the Senate. Tom Price knows the budget process inside and out.
Blythe: What are some noteworthy elements of Price’s plan?
Larry: Price’s plan includes some protections for people with pre-existing conditions, but they’re much more limited than the ACA. You’d only get the protections if you’ve been continuously insured, with no gap. If you haven’t and have a pre-existing condition, you’d go into a “high-risk pool.” In the past, these pools have offered more limited coverage and had very high premiums.
Anna: Price’s plan calls for tax credits, but they are totally different from those in the ACA. In the ACA, people buying insurance on the insurance marketplaces created under the law can get subsidies in the form of tax credits to buy insurance if their incomes are between 100 percent and 400 percent of the federal poverty line. Under Price’s plan, the tax credits would be tied to age, rather than income. So older Americans would get more tax credits, regardless of income, while young adults would get very little.
Notably, there isn’t a replacement for Medicaid expansion in his plan, which is different from other Republican plans that do have some sort of Medicaid enhancement from the pre-ACA era.
Larry: As Anna said, Price’s plan zeroes out the Medicaid expansion. He has also supported the idea of converting Medicaid into a block grant to states.
Blythe: Can we explain block grants a bit?
Anna: Ah, block grants, the wonkiest of health care wonk! (OK, maybe not the wonkiest. There’s plenty of wonk to go around in health care.)
Larry: Right now, anyone who is eligible for Medicaid is entitled to get the benefits, and the federal government and states share in the costs. Under a block grant, the federal government would give each state a fixed sum of money, and states would have a lot of flexibility in deciding what to do with that money, like who to cover.
Anna: Because the idea behind repeal and replace, or even amending the ACA, is to save money, these block grants are not likely to cover the same number of people for the same number of services they currently get.
Larry: About 17 million more people have Medicaid now than did before the ACA. That’s a combination of more people being eligible and more people who were previously eligible now signing up.
Blythe: Gotcha. So if Trump’s choice of Price suggests an endorsement of his plan, that might tell us something about what to expect.
Anna: Right — that’s an interesting tension, Blythe. Trump had insinuated that he would leave Medicaid, Medicare and Social Security alone. But he’s also said he’s a fan of block grants.
Larry: A common theme across Republican health proposals is to cap what the federal government spends. Republicans have very different aims from Democrats. Republicans are looking to spend less, lower taxes and reduce regulation. The result is likely fewer people covered with less generous benefits. Democrats have wanted to increase spending and regulation to get more people covered with more generous benefits.
Harry: It’s time to note that there are very few Democratic governors. That means that under block grants, Republicans would have control of health care policy in the vast majority of states.
Larry: As Harry suggests, states will be really important here. They may play a much bigger role in deciding how Medicaid works and how much to regulate the health insurance market.
Larry: It’s important to remember that we are at the very beginning of what is probably going to be a very big health care debate, involving not just the ACA, but Medicare and Medicaid as well. There will be many twists and turns, and what ultimately comes out of Congress may or may not look anything like these current proposals.
Anna: Yeah, that’s such a good point, Larry. The whole winners/losers approach is fraught. Health care policy is always a series of links, so when you change one, it upsets the rest of the chain.
Larry: Anna is right. It’s really easy to make it seem like everyone is a winner when the proposals are just talking points or bullets. When you get down to writing legislation and the winners and losers become clearer, health reform plans always get more controversial.
Blythe: In terms of Trump’s priorities, what else do we know? Or … think we might know?
Harry: We’re going to find out just how literally we should have taken Trump. A lot of his backers say he should be taken seriously but not literally. Well … I am not sure that works. Not when it comes to this, because people are going to get screwed.
Anna: Right, health care is a space where people feel the direct effect of policy, and pretty quickly.
Blythe: Which people? An article the other day suggested that women could end up paying more.
Larry: Harry’s point is important. Disrupting the status quo in health care is always controversial. And the ACA is now the status quo. People may be divided on the law, but it’s unpredictable what might happen when it becomes clearer what the fate is of the 20 million people who have gotten covered under Obamacare.
Anna: Right — and to loop in what Blythe said, I think some people have probably forgotten that women routinely paid more for health insurance than men before the ACA.
Larry: What women spend on contraceptives has plummeted under the ACA.
Blythe: And Price has opposed the rule saying that insurance plans must include free contraceptives for women, saying that requiring employers to cover it hampers religious freedoms. But to go back to Harry’s point, if Trump were literal, what would we expect?
Anna: Trump has talked a lot about price transparency — forcing doctors and hospitals to be more transparent about what they charge. I don’t think there’d be much argument with that from either side of the aisle. … But there will be from the heath care industry, which has a pretty solid lobby.
Larry: We haven’t even seen the beginning of lobbying that’s going to be unleashed. Every health care industry group has a stake in what’s going to happen here, and their lobbyists are going to crawling all over Capitol Hill.
Harry: The polls indicate, of course, that contraception remains very popular.
Larry: Interestingly, including contraception as a preventive benefit with no copayments is in regulation, not law. So, that’s something the Trump administration could change without Congress.
Harry: If he touches that in a way that limits it — oh, boy, that is not a rail I would want to touch.
Larry: The tricky thing is that there are so many rails here that are potentially hot. It took Democrats decades to thread the political needle and get their version of health reform passed. Republicans are now on the clock.
Anna: Yeah, speaking of: Medicare.
If we’re talking about what to expect from Trump, we’d assume Medicare was going to continue as is, potentially with some changes to age eligibility and that sort of thing. But House Speaker Paul Ryan has been talking about privatizing Medicare, something Tom Price has supported in the past. That would look something like the ACA health insurance marketplaces: Older Americans would get financial support to buy private insurance on a special marketplace, as opposed to the government-run Medicare program as we know it today.
Larry: And while Trump said during the campaign that he was not going to touch Medicare, his transition website now includes a reference to wanting to “modernize” Medicare.
This could really be the perfect storm of health debates — the ACA, Medicaid and Medicare. It’s hard to imagine there’s the time or appetite to risk taking on all three.
Blythe: Maybe the next four years will only be health care policy.
Anna: Blythe, this is what keeps me up at night.
Larry: That would seem to be perilous. Health care has generally not worked out well for politicians who have taken it on.
Harry: Medicare is like the third rail x 100. Older people vote, and Medicare is really popular. And don’t worry, it won’t be the only thing we’ll be talking about. It does seem, however, that health care policy will be far more important than many thought it would in a Hillary Clinton presidency.
Anna: I’ll just add a last point, something Larry brought up when I interviewed him for the last story I wrote about this. There are all these unknowns about what’s going to happen next, but meanwhile, there’s the existing insurance market, and insurers selling on the ACA marketplaces have to start proposing plans for 2018 in the early spring of 2017. These debates will not be worked out by then (they will have just begun, really).
This is very confusing for both people buying plans and people creating them, especially considering the concerns about increasing premium prices this year.
Larry: Anna is right. There is a real risk that the individual insurance market could grow quite unstable as this debate proceeds, especially if there’s a vote to repeal parts of the law, like the individual mandate. Insurers could run for the exits in that scenario. One wonders whether the ensuing chaos would end up being blamed on the Obama administration or the Trump administration.
Anna: Right, in the absence of an individual mandate, insurers will have to assume a sicker population will sign up for coverage (that many healthy people will just opt not to have insurance), which makes the potential for profit much less likely (and means they’ll have to charge way more for premiums than most people could afford). And it’s not just the individual mandate — the law includes a lot of money to subsidize coverage in various ways. If those funds are in question, it’s further incentive for insurers to just exit the marketplace. Also, who wants to start a business when they know they only have customers for a couple of years?
Blythe: OK, so that’s where we think we stand. What will you all be watching for?
Anna: What Trump starts with. I imagine (or maybe hope is a better word) it will be clear pretty quickly whether the goal is to repeal or to reform the ACA. Will this really be something Trump takes on in the first 100 days?
Harry: Watch Trump’s approval rating during this time. If it’s terrible, there may be some real infighting among Republicans about what to do. We will see, though.
Larry: Early in the Trump administration, I’ll be watching for signs of whether he wants an orderly transition to a new system or to undermine the ACA to build support for repeal and replace. There are a number of steps Trump could take quickly to seriously undermine the law.
Blythe: Yes, I think we’ll all be watching — this is just one of the questions we have heading into the next administration. Thanks, everyone.
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