The question of the hour

Healthcare has always been full of uncertainty, but a Republican president and Congress have thrown the future of the Affordable Care and Patient Protection Act, also known as the ACA, into doubt. Any crystal ball regarding healthcare from coverage to costs at best is full of clouds.

The only thing sure today about the ACA is that nothing's sure about what will happen with it and the nation's healthcare system over the next few years.

After campaigning on the idea that the ACA must be revamped or replaced, President-elect Donald Trump recently said he favors keeping key elements, such as insuring people with preexisting conditions and keeping adult children on parents' plans until age 26.

It's far from clear, however, how that would be done without other changes or without a mandate requiring that people be insured, potentially spiking rates.

"What happens to those tens of millions who got insurance through the Affordable Care Act?" Northwell Health spokes­man Terry Lynam asked. "If insurance is not mandatory and coverage not refused to those who seek it, many would wait until they are ill."

While the healthcare system operated for many years without a mandate to be insured, some see that as the linchpin of expanded coverage. Eliminating mandates could leave a sicker system.

"This alone will crash the entire system," said Jason Samel, president of JayMar Insurance Agency in Glen Cove. "Taking away the mandate will drastically reduce the number of healthy insured, making your pool of insured far more sickly."

Samel believes that remaking the healthcare system will mean that health insurance plans themselves will be revamped, a complex and potentially time consuming process.

"It would mean that every plan in America would have to be recalled, rebuilt, repriced and the like," Samel said. "This would mean that every American will lose the health insurance plan they have now."

The change election

Although the past is hardly a way to predict the future, especially when the past includes comments made in campaigns, Donald Trump clearly called for change.

"Real change begins with immediately replacing Obamacare," Trump said before he was elected. "It's a disaster."

Other Republicans rallied and railed against this healthcare legislation dubbed "Obamacare" which they hope to replace rather than refine.

"We can and will replace it if we win this election," Rep. Paul Ryan (R-Wis.), speaker of the House, said just days before Trump's and the Republican party's victories.

Most people agree change could be good, but the question is how radical that should be and whether it will make things better or return to the past.

"There need to be changes within the system, but not a total overhaul," Lynam said. "The system we have has its advantages and flaws. It has facilitated progress in expanding healthcare access. You have more people insured now. You had tens of millions of people who were uninsured prior to the Affordable Care Act."

Lynam said "backtracking from it now could be a mistake" that could risk good things that came out of the Affordable Care Act.

Even if change is in the wind, it's not clear what, if anything, will change for 2017, since turning around our healthcare system is like turning around a massive ship.

"As our nation debates changes to the healthcare system, it's important to take stock of where we are today compared to where we were before the Affordable Care Act," U.S. Depart­ment of Health Secretary Sylvia Burwell said.

Sam Gibbs, executive director of Mountain View., Calif.-based AgileHealthInsurance. com, which provides a wide range of insurance options, says most analysts don't expect major changes to take effect in 2017 plans already purchased.

"Consumers should not read too much into the news of the process and wait to see the final results before making changes to their health insurance plans," according to Gibbs.

Cost of care

Although it's hard to figure out the future, healthcare spending under the ACA has been growing, even if some individuals have been shielded from increases, due to federal subsidies.

Per-capita healthcare spending in 2015 grew by 5.0 percent and overall health spending grew by 5.8 percent, according to a study by the Office of the Actuary at the Centers for Medicare & Medicaid Services.

"Those annual rates continue to be below the rates of most years prior to passage of the Affordable Care Act," according to a statement by the CMS, which found that per-enrollee spending growth in private health insurance and Medicare continue to be "well below the average in the decade before passage of the Affordable Care Act."

A report by CMS found that expenditures are growing primarily because of prescription drug spending and "increased use and intensity of services as millions gained health coverage."

Spending on prescription drugs increased 9.0 percent in 2015, lower than the 12.4 percent growth in 2014, but far higher than the 2.3 percent increase in 2013, according to CMS.

Overall spending on prescriptions in 2014 increased by 4.5 percent for private health insurance, 1.7 percent for Medicare and 3.8 percent for Medicaid, according to CMS.

"As millions more Americans have obtained health insurance, per-person cost growth remains at historically modest levels," CMS Acting Administrator Andy Slavitt said.

Upward and onward

CMS noted that more people are insured than ever, with 20 million people over two years taking private health insurance coverage or enrolling in Medicaid. The percent of the population with health coverage increased from 86.0 percent in 2013 to 90.9 percent in 2015, according to CMS.

Healthcare spending, however, grew 2.1 percentage points faster than the overall economy in 2015, resulting in a 0.4 percentage-point increase in the health spending share of gross domestic product from 17.4 percent in 2014 to 17.8 percent in 2015.

Prior to the passage of the ACA, from 2000 to 2009, healthcare spending increased 2.8 percentage points faster than GDP on an annual average basis.

We're also continuing to spend heavily on healthcare beyond paying premiums, shelling out $338.1 billion out of pocket in 2015 for copayments, deductibles and spending not covered by insurance, excluding premiums, up 2.6 percent, according to CMS.

Even if it's not clear what Trump and Congress will do, some insurers are scaling back or exiting the individual insurance market created by the government through the ACA.

Samel said Aetna left the ACA program for individuals in every state and United Healthcare exited 37 of 39 states as a provider for individuals. He sees fewer insurers covering individuals.

"The insurers are leaving the market because they have lost far too much over the past four years," Samel said.

Others say the outcome of mergers could have a massive impact on health insurance, regardless of what else happens in healthcare. The U.S. Department of Justice is challenging the Aetna-Humana and Anthem-Cigna mergers.

"If the court rules in favor of the mergers, competition will be significantly lowered in the market for Medicare advantage and on the Affordable Care Act's health insurance exchanges, which could lead to higher ­premiums and lower coverage," according to Jack Curran, an analyst at Los Angeles-based research firm IBISWorld.

Aetna and Humana argue this isn't about reducing competition, but increasing efficiency as they seek to "bring our technology, services and solutions together to offer consumers new products that deliver a simpler, higher-quality and more affordable healthcare experience."

Gibbs thinks technology will streamline healthcare as telemedicine, or long-distance medicine, catches on.

Mobile devices could make it easier to make appointments and get test results, as Gibbs sees consumers demand an "easy, effective digital experience" as well as hands-on care.

"Both providers and insurers will continue to refine their online interfaces in 2017, especially for smartphones," according to Gibbs.

Published: Tue, Dec 20, 2016

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