WASHINGTON (MEDIA GENERAL) — Republicans have voted to repeal Obamacare dozens of times since it passed in 2010, but President-elect Donald Trump has vowed to be the man who finally declares the program dead.
In fact, Trump promised during the campaign to undo the Affordable Care Act (ACA) on day one in office.
After the election, the billionaire businessman visited DC and doubled down, telling congressional leaders that repealing and replacing the sprawling health care program is one of his top three priorities, along with immigration and jobs.
Obamacare has no doubt struggled in the price and public perception departments.
“If you like your doctor, you can keep your doctor. If you like your health care plan, you can keep your health care plan,” was a false statement oft repeated by President Obama during the ACA sales pitch, and turned out to be an albatross permanently affixed to the White House.
More recently, just a month before Election Day, the feds were forced to announce that customers would face an average national premium hike of 22 percent.
House Speaker Paul Ryan and Senate Majority Leader Mitch McConnell have signaled an eagerness to repeal and replace the program.
But that process is easier promised than executed, given Obamacare’s numerous intricacies.
Sen. Bill Cassidy, R-La., a physician, has predicted that a full repeal could take two years.
Trump has been extremely vague on most relevant details, as is his custom, but insists a simultaneous repeal and replace maneuver will be possible during his first days in office.
So here’s what we know (and don’t know) so far about his plan, based on the scraps of information he’s dropped during previous rallies and interviews.
Prior to Obamacare, insurance companies legally and routinely excluded coverage of customers’ medical conditions if they were deemed “pre-existing.”
Many Americans with chronic conditions like diabetes and high cholesterol could obtain new medical coverage, but weren’t allowed to bill insurance companies for routine treatments of these illnesses, leading to sky high out-of-pocket expenses.
The ACA made the practice of excluding select conditions illegal, forcing insurers to cover all illnesses, pre-existing and otherwise.
Trump says his plan will retain this provision.
“It happens to be one of the strongest assets,” he said of the pre-existing condition coverage on CBS’ “60 Minutes.”
It’s also a budget buster.
What bogged down Obamacare to begin with is too many sick people (many with pre-existing conditions) signed up for coverage, and not enough healthy people balanced them out by paying their premiums and not seeking expensive treatments.
Absent this equalizing factor, insurance companies couldn’t hold costs down and sometimes dropped out of the Obamacare system altogether.
When you look at the budget, this will be a difficult promise to keep.
Adult child coverage
Trump also vowed on “60 Minutes” to continue giving parents the option of cover their adult children until the age of 26.
“It adds cost, but it’s very much something we’re going to try and keep,” said the president-elect.
Prior to ACA’s passage, most insurance plans kicked subscribers’ children off the rolls once they turned 18 or graduated college.
With an entire generation of millennials still living at home, struggling to make ends meet and paying massive student loans, the ability to remain on their parents’ (often more affordable) family insurance plans is a welcome option.
When Democrats crafted the ACA, they included an “individual mandate” requiring all Americans to buy medical insurance, or pay a penalty.
It was a way of a) increasing the number of insured Americans while b) decreasing the risk of only unhealthy people signing up for new plans.
By diluting the “risk pool” for insurance companies, they could theoretically keep prices down.
This is the axis on which affordable health care turns.
Although the individual mandate concept was originally introduced by conservatives in 1989, it fell out of favor with right-leaning members of Congress by the time Obamacare passed.
Trump’s campaign website backs a repeal of the mandate.
But if he plans to continue covering pre-existing conditions, Trump would likely need to offset the cost by ensuring a wider risk pool through a mandate.
For the time being, this element is in limbo.
For states that didn’t opt in to the Obamacare system, there’s a federal health care exchange program where residents can obtain coverage.
But for states that did decide to work with the federal program, insurance exchanges were set up on a state-by-state basis.
Customers could only buy health care offered by companies in their own state.
The president-elect plans to nix state-based exchanges.
“Trump has said he also wants to allow insurers to sell policies across state lines to boost competition,” reports NPR.
This is an instance where the GOPs free market principles will decisively win out.
Obamacare bans insurance companies from placing annual and lifetime caps on coverage for enrollees, regardless of cost.
It wasn’t long ago that insurers could refuse to pay for treatments that exceeded a certain amount of money per year or in a lifetime, often forcing customers with major injuries or serious illnesses into destitution.
That’s no longer allowed, but a total repeal of Obamacare would likely allow companies to reinstitute caps in order to save on costs.
This issue is also a toss-up.
Clearly, many more questions exist for Trump’s health care plan than do specifics – not to mention the dollars and cents of its replacement.
Speaker Ryan has proposed a detailed replacement plan, but it remains to be seen whether Trump will adopt its recommendations as his own.
Follow Chance Seales on Twitter: @ChanceSeales