Two days after the election, President-elect Donald Trump met with outgoing president Barack Obama to start planning the transition. Until then, the Republican successor to the White House had adamantly insisted that the Affordable Care Act (ACA) had to be repealed on day one of his administration. After an afternoon with Obama, Trump appeared to back down a little from that campaign promise.
“I told him I will look at his suggestions, and out of respect, I will do that,” Trump said of the discussion the two had about the future of the ACA. “Either Obamacare will be amended, or repealed and replaced.” Conservatives began to fret that Trump would settle for tweaking the ACA around the edges, particularly when he talked about keeping a few of the more popular components of the program. Republicans in Congress renewed their pledge to send a repeal quickly to the White House in the next session and said they expected Trump to sign it, even while some wondered whether it remained a priority.
Trump settled that question decisively this week. He appointed Rep. Tom Price (R-GA), a medical doctor and staunch opponent of Obamacare, as the new Secretary of Health and Human Services. As a member and former chair of the Republican Study Committee and the Congressional Health Care Caucus, few Republicans on the front lines have as much insight into the ways in which the Obamacare can and should be dismantled.
Washington Examiner reporter Philip Klein spoke with Price at length about the ACA for his 2015 book Overcoming Obamacare, and Price emphasized the need for repealing the existing law first. "[T]he first step out of the gate for Obamacare is a step in the wrong direction,” Price explained, “and that is for government control over every aspect of health care. So it's hard to fix the system that they have put in place without ending that premise that government ought to be running and controlling health care."
In fact, Price has attempted to repeal and replace Obamacare since before its passage. Democrats have repeatedly accused Republicans of having no alternative to the ACA for health insurance reform, but Price introduced a bill in July 2009 that would have offered reform on free-market principles rather than a federal government takeover of the insurance markets.
Called the “Empowering Patients First Act,” it included the following:
- Tax incentives for buying health insurance rather than a mandate and tax penalties for opting out.
- Federal block grants to states predicated in part on establishing high-risk pools for people with pre-existing conditions.
- Expansion of health-savings accounts (HSAs) for pre-tax medical expenses. Freeing up interstate insurance sales to allow for greater competition.
If that sounds familiar, it’s because Price had a lot of influence on the latest proposal from House Republicans on an Obamacare replacement. Called “A Better Way,” House Speaker Paul Ryan published it this summer to give Republicans a platform on which to use the election as a referendum on the Obamacare. It includes the same concepts and goals of Price’s 2009 legislation, and Price worked closely with Ryan to keep the focus on free-market reforms mixed with tax credits and state jurisdiction.
While a full repeal would have to originate in Congress, Price’s nomination promises quick action to roll back regulatory changes that come from the blank-check authority given to HHS by the ACA. The controversial contraception mandate will almost certainly be at the top of that list. Price has opposed that from the moment Kathleen Sebelius issued the regulation, specifically citing its infringement “with our fundamental right to religious freedom.”
Twila Brase, president of the Citizens' Council for Health Freedom, reminded the Examiner’s Robert King that Price can easily undo most of what Sebelius implemented while waiting for Congress to act. "There are tens of thousands of pages of Obamacare regulations that can be rescinded, amended or left unenforced on the way to repeal, and we encourage him to make every effort to begin shutting down Obamacare by shutting down its regulations.” Such are the vulnerabilities of regulatory legacies.
Democrats have been quick to counter with accusations that Trump and his new administration will leave low-income Americans without health coverage. Obamacare also expanded Medicaid, which most states have adopted, and which accounts for nearly half of the claimed 20 million consumers who gained insurance after its adoption. Repealing Obamacare, its advocates claim, will leave those Americans in the lurch.
Trump’s second appointment this week provides a clear answer to those accusations. Seema Verma will take over the Centers for Medicare and Medicaid Services after having worked with vice-president elect Mike Pence to craft Indiana’s Medicaid expansion, as well as with Kentucky’s Matt Bevin and a handful of other Republican governors. Verma helped create Healthy Indiana 2.0 plan (HIP), a program that mixes the base coverage of Medicaid with tax credits and HSAs to produce incentives making utilization more efficient and effective.
In August, Verma wrote of the need for market-based reforms of Medicaid. She emphasized the need to introduce price signals to consumers of government-run plans as a means of both saving costs and improving outcomes. “Contributions are a way for members to demonstrate personal responsibility, but they also encourage members to stay engaged with their health plan, providers, and overall personal health,” Verma explained. “Because HIP Plus members’ own dollars are at stake, they have “skin in the game” and therefore an incentive to make cost-conscious health care decisions.”
The two appointments make an impressive pair for Americans hoping to see an end to the ACA, its skyrocketing costs, and its increasing lack of choice and coverage. Price has the legislative and professional background needed to advise Congress on a plan to replace Obamacare and the expertise to put it in place, while Verma has the experience in handling Medicaid to ensure a smooth transition and reform. Trump has sent a Price signal all his own on Obamacare – don’t bet on amendments.