A
s we look ahead to the uncertainty of an unlikely presiden-
cy, there are more questions than answers about what the
U.S. healthcare system might look like under Donald
Trump's proposed policies.
Is repeal and replace possible?
About 21 million Americans are insured through the Affordable Care
Act's (ACA) Medicaid expansion and insurance exchanges.
Republican leadership, including Mr. Trump, have indicated they want
to come up with a way to repeal Obamacare without leaving millions
of their constituents without coverage. But President-elect Trump's
reforms might turn out to be less drastic than he promised. The ACA,
which became law in 2010, is complex legislation that's already
entrenched in the nation's healthcare system. Its policies extend well
past insurance exchanges to touch on payment reform, quality out-
come reporting and patient-centered care. Republicans might soon
discover they'll have to settle for remaking and renaming, not repeal-
ing and replacing, Obamacare.
Some of the ACA's insurance reforms — eliminating adverse selec-
tion, underwriting people who couldn't otherwise afford insurance,
encouraging healthy individuals to sign up to increase pools for high-
risk patients — make sense, says anesthesiologist David Shapiro, MD,
past president of the ASC Association. "If all that gets repealed, how
do you replace it and what do you replace it with?" he asks.
"Everybody wants the same thing, but differ on how to get there."
The Republicans will likely use budget reconciliation to repeal ele-
ments of the ACA that have substantial impact on the federal budget.
That way forward has already been established. Last January, the
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