Rep Price has also voiced concern that many of the pilot projects are hospital-centric, and “given his experience as a private practice physician, it is likely that he will be sympathetic to concerns that have been raised by the clinical community,” according to Dr Wilensky. Additionally, he and other Republicans are generally supportive of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), though they may review recently released regulations–and develop new ones–pertaining to its implementation.5

MACRA repeals the flawed formula that results in physician pay cuts, sets up frameworks for physician rewards, and consolidates quality reporting programs. “The secretary and the CMS administrator are also likely to look for ways to make it easier and faster for states to receive CMS waivers and to provide as much flexibility as possible within legislative constraints and budgetary concerns.”

She noted that Republicans could accomplish many of their desired changes to the ACA by modifying it instead of repealing it, though they may not be willing to drop the hardline stance. However, there could be backlash if Congress reversed the benefits that more than 20 million people in the US now have without offering an adequate replacement.6 “In particular, repeal of the ACA risks losing the coverage gains that have occurred since passage of the act, unless new legislation provides an adequate substitute,” cautioned another viewpoint paper published in JAMA.2


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As President Obama himself wrote in JAMA August 2016, there has been a 43% reduction in the uninsured rate: In 2015, it was 9.1% compared to 16.0% in 2010, a change attributed to the law’s reforms.7 Meanwhile, Americans are divided in their satisfaction with the ACA, with 51% reporting disapproval and 44%  reporting approval, as well as their view of the government’s role in health care, with 51% of respondents for federal involvement and 46% against it.8

While repealing ACA funding would be relatively easy to do, “ensuring that 20 million newly-insured individuals retain coverage will be more challenging,” wrote Dr Wilensky. “Moreover, it is unclear if the market-oriented reforms in the republican plan will be any more successful in making health care more affordable for US residents than the ACA has been.”

References

  1. Wilensky GR. The future of the ACA and health care policy in the United States. JAMA. 2016; doi:10.1001/jama.2016.18762
  2. Gostin LO, Hyman DA, Jacobson PD. The affordable care act: moving forward in the coming years. JAMA. 2016; doi:10.1001/jama.2016.18908
  3. Sparer M. Maintaining insurance access under Trump — a strategy. N Engl J Med. 2016; doi:10.1056/NEJMp1611202
  4. Bundled payments for care improvement (BPCI) initiative: general information. Centers for Medicare & Medicaid Services website. https://innovation.cms.gov/initiatives/bundled-payments. Updated November 28, 2016. Accessed December 23, 2016.
  5. FAQ on MACRA and Medicare payment reform. American Academy of Family Physicians website. http://www.aafp.org/practice-management/payment/medicare-payment/faq.html. Updated September 2016. Accessed December 23, 2016.
  6. Oberlander J. The end of Obamacare. N Engl J Med. 2016; doi:10.1056/NEJMp1614438
  7. Obama B. United States health care reform progress to date and next steps. JAMA. 2016;316(5):525-532.
  8. Blendon RJ, Benson JM, Casey LS. Health care in the 2016 election – a view through voters’ polarized lenses. N Engl J Med. 2016;375(17):e37.