The future of the Affordable Care Act looks both bleaker and cloudier with President-elect Donald Trump's nomination for his administration's top health jobs.
House Budget Committee Chairman Tom Price, R-Ga., a surgeon and outspoken critic of the law, was named to head the Department of Health and Human Services (HHS). Price introduced a replacement plan last year that includes some elements that are similar to the ACA, but removes the mandate that everyone have insurance.
Supporters of his bill say it would make insurance more attractive because it would be less expensive for many, especially the healthy, younger people who felt priced out of the market.
The nomination of the staunchly anti-abortion rights Price struck fear in many ACA and reproductive rights supporters. Former Republican Senate counsel Christopher Condeluci says, however, that Price's ACA replacement doesn't vary too much from other alternatives proposed in Congress.
"Some people may disagree on ideological grounds, but many (provisions) are consistent with what Republicans have supported post-ACA's enactment," says Condeluci, who helped draft the ACA and now heads CC Law & Policy.
Health care economist John Goodman, who helped draft another Republican-backed ACA replacement bill, called Price the "most thoughtful and knowledgeable person" Trump could name for the job.
"It doesn't really matter how conservative he is on social issues" as Price will need to work within the administration and with Congress and "is not going to be able to dictate his ideas to the world," says Goodman.
Women's rights advocates aren't so confident.
"We need a health secretary who will fight to ensure high quality care is available and affordable to all and who will make women’s health needs, including reproductive health, a priority," Debra Ness, president of the National Partnership for Women & Families, said in a statement. "This is essential to strengthening families, our economy and the country."
If Price's bill was enacted, two key tenets of Obamacare opposed by some conservatives would remain: Universal insurance coverage and tax credits to help pay for insurance.
"Those are stumbling blocks for a lot of Republicans and are the two most important reasons there isn't a Republican alternative that has united the Republicans in Congress and outside," says Goodman.
Conservative Republicans tend to prefer tax deductions over credits, which they see as a redistribution of income, although Goodman notes deductions don't help the nearly half of people who don't pay income tax.
Any legislation likely to be signed by the next president would change dramatically from its initial state and be the result of many compromises, as the ACA was. Condeluci says there's "nothing magical" that makes Price's plan much better or different.
But if the resulting law mirrors Price's closely, big changes are in store.
What would change most:
• Preexisting coverage. Those who are sick and maintain consistent insurance coverage wouldn't have to pay more than others who are healthy. Those with preexisting conditions who go without insurance and "game the system," as Goodman puts it, would be penalized. If they can't afford the high prices insurers are able to charge them, they would likely be able to buy insurance through a high-risk pool. That's similar to what was in place before the ACA opened the insurance exchanges to all people, but Price's plan calls for less money to help patients pay for insurance — so pricier plans — than a proposal by House Speaker Paul Ryan, R-Wisc.
• You get what you pay for.. Insurance plans could cover fewer of the benefits currently required by the ACA, which would make them less expensive (although many say less valuable). Those who wanted a better choice of doctors and benefits could opt for pricier plans that offer them. Many of those ineligible for hefty subsidies to pay for their Obamacare plans say the plans they wound up with had such high premiums and deductibles that it wasn't even like having insurance. Meanwhile, women long past childbearing age had to buy plans with maternity and birth control coverage.
• Age really matters.Tax credits would be based on age rather than income. That would solve the problem of getting more young, healthy people into the market to offset the costs of covering older ones. But it could also mean that older people who get lower credits — and likely have more health issues — may not be able to afford plans. That could leave them waiting to get free care at emergency rooms when their health conditions are advanced — and most expensive. But Goodman says it is also more fair as older adults don't typically have college loans and mortgages to pay off.
• Coverage for the poor unclear. The ACA's expansion of Medicaid to all adults below the federal poverty limit could be in jeopardy. It would likely be replaced or paid for by federal block grants that would give states far more discretion in designing benefits. But Trump's nomination of health policy consultant Seema Verma to head HHS' Centers for Medicare and Medicaid Services further suggests an inclination toward flexibility for states on Medicaid. She helped design Indiana's alternative Medicaid expansion plan, which was pushed by Vice President-elect and Gov. Mike Pence and approved by the Obama administration.
"I actually think Seema and her colleagues will be constructive, as opposed to resistant, to creative health care reform ideas states may come up with," says Condeluci.