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Trump Says ACA Repeal May Take A Year; Price Confirmed For HHS

The repeal and replacement of the Affordable Care Act (ACA) could take up to a year — a sudden, significant departure from President Donald J. Trump’s earlier assertion, made just last month, that it would only take a matter of weeks.

In an interview with Bill O’Reilly of Fox News, Trump was asked whether an ACA replacement would arrive in 2017 and replied “yes, in the process and maybe it’ll take till sometime into next year but we’re certainly going to be in the process.”

Trump had previously stated that the repeal and replacement of the ACA would be “essentially simultaneous” and that it would occur in the weeks following the confirmation of his pick for HHS Secretary, Rep. Tom Price (R-Ga.).

The extra time could be just what Republicans need to regroup. While an ACA repeal was an easy campaign promise, it has clearly turned out to be a difficult exercise in governing, says Bradley Coffey, government affairs manager for the AAOE in Indianapolis. “I think really this is the president trying to take some heat off of Congressional Republicans for the moment.”

Though Trump’s latest statement was vague, practice managers welcomed the news. “This change to at least a year makes a lot more sense to me, as a practice administrator,” says Barry Hubert, CMPE, COPM, administrator at Blue Ridge ENT in Boone, N.C. and also president-elect of the AOA. Trump’s promise to deliver a comprehensive ACA replacement within weeks had been viewed skeptically by many in the healthcare industry, Hubert says.

Reality hits for GOP lawmakers

The obstacles to Trump’s original plan materialized clearly in Congress, with Republican members in both chambers acknowledging the stakes. If the repeal-and-replace is botched in a way that destabilizes insurance markets and leaves Americans without coverage, “Republicans will own it lock, stock and barrel, and we’ll be judged on that,” Rep. Tom McClintock (R-Calif.), said during the GOP’s annual retreat in Philadelphia on Jan. 27.

That date, Jan. 27, had been set by Republicans as an informal deadline to pass a repeal bill, but the day came and went without action. The key stumbling block is the lack of any consensus plan, Coffey says. While Republicans have campaigned on repealing the ACA, and several have offered replacement legislation, there is no single replacement program ready to go.

Republicans are also facing increased resistance to a wholesale repeal that would cause many to lose coverage. At town halls across the country, several Republican Congressmen faced scores of constituents angry at the prospect of suddenly losing their health insurance coverage, and were shouted down as they tried to answer questions about the ACA repeal.

Trump’s earlier statement about a fast repeal-and-replace was seen as torpedoing earlier plans by Republicans to quickly pass a repeal-only bill that would tack on a two or three-year effective date to claim credit for a repeal while giving Congress, HHS, and industry stakeholders time to converge on a comprehensive, detailed replacement program.

As we reported in the January issue of The Business of Medicine, Republicans would also need at least several Democratic votes to pass a true ACA replacement; while the reconciliation rules can be used to defund and effectively repeal the ACA with a simple majority, those rules can’t be used to pass the replacement. Trump’s latest statement could buy valuable time to try and win Democratic support; the window of one year and change could signal a shift back in the direction of a repeal bill with a replacement program to come later, experts believe.

Tom Price confirmed for HHS

The ACA repeal effort has received a boost with the successful confirmation of Rep. Tom Price (R-Ga.) as HHS Secretary, albeit under a party-line, 52-47 vote in the Senate. Price, a former orthopaedic surgeon, is seen as being well-versed in healthcare policy, having authored a comprehensive bill to replace the ACA called The Empowering Patients First Act of 2015 (H.R. 2300). Price, a staunch conservative, has received a mixed reception from physicians, though the AMA was quick to endorse his nomination.

Price’s legislation (see related story, pg. 5) has been held up as a basis for the eventual Republican ACA replacement, but it did not include a delayed effective date or much in the way of measures to facilitate a stable transition from the current ACA.

With the extra time afforded to Republicans based on Trump’s latest statement, Price’s plan may no longer be as crucial as it was. His legislation would drastically reduce subsidies by replacing them with age-based tax credits. It would also reverse the ACA’s Medicaid expansion in favor of conservative models such as those launched by Seema Verma, a healthcare consultant that Trump has tapped to head CMS. Verma will begin her confirmation hearings with an appearance before the Senate Finance Committee on Feb. 16.

Whatever Republicans decide on, they will need to act quickly to stabilize markets and reassure insurance companies that still have ACA plans in effect, experts say. Already, many insurers are fleeing the individual market to avoid losses should a repeal bill pass that would eliminate current federal subsidies for low-income beneficiaries.

Next steps in Congress

The House Energy and Commerce Committee has been working with the non-partisan Congressional Budget Office (CBO) to craft elements of an ACA repeal bill that it hopes to introduce on March 1. House Speaker Paul Ryan (R-Wis.) has said that he wants to pass repeal legislation in the first quarter of 2017, which would give lawmakers until the end of March.

At this point, it’s not clear whether a repeal bill introduced in the House of Representatives would deliver on President Trump’s promise of a replacement to go along with the repeal, though if the GOP meets the March 1 deadline, it would be well on its way to satisfying Trump’s ambiguous “sometime next year” goal for fulfilling the ACA repeal-and-replace promise.