Maintaining Insurance Access Under Trump

In a New England Journal Of Medicine Perspective, “Maintaining Insurance Access under Trump — A Strategy,” Michael Sparer, PhD, JD, professor and chair of the Department of Health Policy and Management at the Mailman School of Public Health, says that while major changes to the ACA through the budget reconciliation process in a Donald Trump presidency are nearly certain, eliminating ACA insurance coverage for the millions who have it is unlikely and has political risks for the new administration. However, growing concern about the long-term viability of many of the insurance exchanges also complicates the issue. Sparer says that increased reliance on Medicaid managed-care could stabilize the ACA exchanges --should they survive-- but could also play a key role in preserving coverage should the Trump administration enact a “repeal and replace” strategy.

“While most exchange markets are likely to stabilize as insurers adjust prices to match expected costs, it still makes sense to have a fallback insurance option,” notes Sparer. He suggests that relying on Medicaid as an insurance safety net points to the best path toward ensuring a competitive market for people who buy coverage through the individual and small group markets, in contrast to the “big five” insurers, whose primary focus will always be the large-group market.  As a bonus, according to a review of the literature, the number of uninsured people declines more rapidly in Medicaid-expansion states, uncompensated hospital care decreases and overall care to beneficiaries improves.

“President Trump should adopt Medicaid as the fallback option for the exchanges, perhaps emphasizing to Republicans that the coverage would be provided by private firms. Such a plan would make our insurance markets more efficient, more competitive, and more likely to deliver good health care to millions of Americans.”