More Than 20 Million Could Lose Access to Care Under the Trump Administration

Perhaps what is most notable about Trump's plan to replace the Affordable Care Act is what isn’t included: any mention of the incredibly popular protections for those with pre-existing conditions and the birth control benefit.

In place of pre-existing conditions protections, Republicans often suggest pushing people into high-risk insurance pools, as Rewire has previously reported. Trump’s own ACA replacement plan also includes these pools, which often offer care at very high cost. Joe Raedle/Getty Images

“On day one of the Trump Administration, we will ask Congress to immediately deliver a full repeal of Obamacare,” claims President-elect Donald Trump’s position paper on the Affordable Care Act (ACA), which he released in March of this year.

Trump’s plans for repealing and replacing the ACA have repeatedly shifted over the course of his run for the White House, as well as in the time since he won the election. Given his propensity for changing his mind, it is impossible to say exactly what will happen or how Trump plans to work with Congress with regard to the policy. However, his existing plans for the health-care law provide a glimpse into what could happen after Trump takes office in January.

Trump’s transition website offers many of the same steps proposed in his position paper, including offering Health Savings Accounts (HSAs), allowing states to self-regulate health insurance, allowing citizens to purchase insurance across state lines, and establishing high-risk pools.

The plan on the new site offers no specifics about such proposals. Questions about how he would set his plan in motion, what effect his proposals would have on historically low rates of uninsured people achieved under Obamacare, and what the repeal of the ACA would mean for the 21.3 million people who have gained insurance since the key provisions of health-care reform were implemented are completely ignored.

The transition site also includes a bulleted list of other health-care priorities the president-elect claims he would work with Congress and the states to achieve, though it is unclear whether those proposals are to be included in an as-yet unidentified ACA replacement strategy. Those include working to “protect individual conscience in healthcare,” a likely reference to conscience clauses that allow those claiming moral objections to discriminate in providing services, as well as working to “protect innocent human life from conception to natural death, including the most defenseless and those Americans with disabilities.”

But perhaps most notable is what isn’t addressed on the site: the ACA’s incredibly popular protections for those with pre-existing conditions. As explained by the Department of Health and Human Services, the ACA ensured that “health insurance companies can’t refuse to cover you or charge you more just because you have a ‘pre-existing condition’—that is, a health problem you had before the date that new health coverage starts. They also can’t charge women more than men.” This guarantees that people, no matter whether they are seeking private or public coverage, aren’t denied insurance or charged more because they have a medical history that includes conditions as common as asthma, cancer, heart disease, and diabetes.

If congressional Republicans under a Trump administration move ahead with their plans to dismantle the health-care law, that could mean a loss of protections for an estimated 36 million to 122 million people with pre-existing conditions.

During an interview published last Friday with the Wall Street Journal, Trump changed his mind again, claiming he’d be willing to keep this part of the ACA, as well as the provision allowing young people to stay on their parents’ insurance until the age of 26. But he didn’t say how that would work, especially since many of these provisions don’t function on their own. As Margot Sanger-Katz explained for the New York  Times, keeping the popular parts of the health-care law “while jettisoning others is most likely no fix at all.” That’s because the provisions of the ACA “that make the insurance market feel fairer for sick Americans who need it can really throw off the prices for everyone else. That’s why Obamacare also includes less popular policies designed to balance the market with enough young, healthy people.”

According to health policy experts, the GOP lacks the filibuster-proof majority in Congress to repeal these provisions in the first place, and are more likely to attempt to repeal the ACA through a budget reconciliation bill that would not allow these safeguards to be overturned. However, the prospect of losing these protections and policies is very real for the millions of Americans who rely on them. And if his flip-flopping on abortion rights is any indicator of how a President Trump will behave in the coming years, we can hardly expect him to stay true to his word on preserving them.

In place of pre-existing conditions protections, Republicans often suggest pushing these people into high-risk pools, as Rewire has previously reported. Trump’s own ACA replacement plan also includes them. These refer to state-sponsored health plans for those with pre-existing conditions, but according to healthcare.gov, “your premium is up to twice as much as you would pay for individual coverage if you were healthy.”

Analysis conducted by the Center for American Progress (CAP) in 2008 found that high-risk pools often don’t offer suitable alternatives for those with pre-existing conditions, as cost consistently provides a barrier to enrollment. The high-risk pools created “a greater burden on individuals with expensive medical conditions who have already spent large amounts of their income on health care,” the report said.

An overview of high-risk pools in relation to ACA replacement plans written by nonprofit health-care policy organization the Commonwealth Fund in 2015 similarly found that “these entities simply are not a realistic alternative to coverage requirements under the ACA” because they create high costs for both consumers, and state and federal governments, while providing “much less than optimal coverage, often with annual and lifetime limits, coverage gaps, and very high premiums and deductibles.”

As Ian Millhiser explained for ThinkProgress, at best, these pools can be thought of as “a way to maximize the insurance industry’s profits while shifting the costs of our health care system onto the taxpayers.”

“If the government takes on the burden of insuring the most expensive individuals—and only the most expensive individuals—then that’s a bonanza for the insurance companies because they will be left with a pool of less expensive (and more profitable) consumers,” continued Millhiser.

Not to mention that Republicans have previously signaled that they have no interest in actually paying for these proposed high-risk pools.

Also unmentioned in Trump’s plan is whether the ACA’s birth control benefit, which requires insurers to cover all FDA-approved forms of contraception without co-pays, would remain. In a recent interview on CNN’s State of the UnionHouse Speaker Paul Ryan (R-WI) refused to say whether the benefit would end, but others who are supposedly working with Trump haven’t been so shy about their plans. Ed Haislmaier, a senior research fellow in health policy studies at the Heritage Foundation—which has been working with Trump since his presidential campaign—told Medscape that his organization had been in talks with the president-elect’s transition team about dismantling aspects of the ACA, and that he suspects getting rid of the birth control benefit “will be one of the first things they will do.”

“It’s easy to do, and it gets rid of a controversial problem in the law,” Haislmaier claimed.

Alina Salganicoff, vice president and director of women’s health policy at the Kaiser Family Foundation, told Medscape that Trump wouldn’t need to go through Congress or completely repeal the ACA to get rid of this aspect of the health-care law. Instead, his administration could simply issue a new directive saying that birth control is not a preventive service.

However, without the regulation, coverage wouldn’t be as complete and many of the estimated 48.5 million women affected by the birth control benefit would be forced to pay for some of their contraceptive care out-of-pocket. And if congressional Republicans did eventually succeed in overturning the health-care law entirely, those who received insurance through it and depended on it to pay for their birth control would be left in the dark.

In the meantime, if the GOP was able to pass an aforementioned budget reconciliation bill, it could limit Medicaid spending, thus affecting millions of people who rely on it for care—including reproductive health services.

This has already led many to pursue long-acting reversible contraception options such as IUDs ahead of Trump taking office.

“These are real concerns that women have,” said Dr. Stacey Leigh Rubin, who practices obstetrics and gynecology, about her patients in an interview with FiveThirtyEight. “They’re scared and anxious. They want to talk about it.”