In contemplating the ways in which physicians may be affected by the possible repeal of the Affordable Care Act (ACA)-and certain features of any legislation that may replace it-a good place to start is with the person selected by President Trump to be the Secretary of the Department of Health and Human Services (HHS) - Representative Tom Price of Georgia, a physician himself. If confirmed, Dr. Price would be only the third physician in the 63-year history of HHS and its predecessor, the Department of Health, Education and Welfare, to serve as Secretary. Among other things, HHS controls Medicare, Medicaid, and the Affordable Care Act's Federal health insurance exchange.
As a Congressman, Dr. Price introduced legislation to repeal the ACA, including its expansion of Medicaid and subsidies for the purchase of private insurance, spearheaded efforts to correct flaws in Medicare's formula for paying physicians, and supported changes in malpractice laws so as to make it easier for physicians to defend themselves. He also supported changes in Medicare that would permit physicians to avoid fee limits by entering into agreements with patients, and favored changes in antitrust laws that would increase physicians' bargaining leverage in negotiating reimbursement rates with commercial third-party payers. These last items were not signed into law, but provide a glimpse into Dr. Price's mindset as an administrator.
Based upon a review of President Trump's position paper on healthcare reform released during the campaign, and referenced in an earlier post on this blog, as well as certain statements made at that time, there is evidence that approximately 20 million people who gained health insurance coverage under the ACA may lose their healthcare insurance. As covered lives are removed from the health insurance rolls due to the likely elimination of subsidies, the repeal of the individual mandate, the defunding of the Medicaid expansion, as well as the possible loss of coverage to those individuals with pre-existing conditions, together with young adults ages 18 - 26, will physicians in private practice continue to treat people they know have no coverage and little or no ability to pay? If not, these people shall likely be forced to seek care through their local hospitals' emergency rooms, thereby increasing the burden-both financially, in terms of uncompensated care, and with respect to the number of patients to be treated-on such emergency rooms.
While it may be early to speculate on the impact of possible repeal or reconciliation of the ACA, the economic effects of these changes must be considered by the lawmakers and anticipated by the provider community. While the only constant in life is change, drastic change in this arena has a domino effect to which all parties must be aware.