7 things to know about the future of Obamacare

You’ve seen the headlines and you’ve heard the slogans: Obamacare is on the chopping block and President-elect Donald Trump is going to replace it with “something terrific.”

But what are the new president and Congress really going to do? How much of the current law will really go away? And what could “Trumpcare” look like?

In case it’s been a while since you read about the Affordable Care Act and the GOP replacement plans, here’s a refresher on the biggest Obamacare issues.

Insurance mandates

The current law: This one has been hard to miss. Obamacare, for the first time, required Americans to have health insurance or pay a tax penalty.

What’s at issue: Nobody likes being told what to do. 

The penalty is supposed to discourage people from waiting until they are sick to get health insurance. This keeps premiums in check by helping insurers get a good mix of sick and healthy consumers.

But this is the most unpopular part of Obamacare.

What could change: The mandate is almost certainly on the way out. Republicans have made it the top target in their repeal plans.

Less clear is what the GOP will put in place. Even Republican lawmakers acknowledge that insurance markets will not work unless there is some penalty for not signing up for coverage.

One idea they have talked about is allowing insurers to charge consumers much more for premiums if they go on and off health insurance.

Guaranteed coverage

The current law: Critics don’t like to admit it, but this part of Obamacare really was revolutionary.

The guarantee allows Americans to get health insurance even if they’re sick. That put an end to insurers denying coverage to people who had preexisting medical conditions.

What’s at issue: What’s not to like about a guarantee? The rub is that it has made health insurance more expensive.

Sick people typically have higher medical expenses. Because insurers spread costs among all customers, that makes premiums higher for people who don’t use the doctor or hospital very much.

What could change: Republicans are smart enough not to say they’re going to take this away.

But some of their proposals let insurers make sick people pay more.

The GOP also wants to slash requirements that insurers offer a basic set of benefits, which could mean people buy health plans that don’t cover some vital services, such as substance abuse treatment.

Trump could use his executive power to roll back some of these rules soon after inauguration. But scaling back this guarantee would likely require some help from Democrats. That could be tough. 

Insurance marketplaces

The current law: Buying health insurance was supposed to be like shopping online for a hotel room. The Obamacare marketplaces, such as HealthCare.gov, allow people who don’t get health benefits at work to compare plans. And low- and moderate-income consumers get federal subsidies to help pay their monthly insurance premiums.

What’s at issue: It’s been a rough ride for these marketplaces.

Though subsidies helped many people find plans they could afford, some Americans who earn too much to qualify for aid have seen their premiums skyrocket as insurers struggled to adapt to the new marketplaces.

That created a lot of angry customers in some parts of the country.

What could change: Unclear.

Republicans are gunning for the marketplaces. Their repeal plans call for eliminating the subsidies. And they’ve said they want to scrap the rules that require health plans to include basic benefits.

But major patient groups are warning that millions of sick people could be left without protections, which could make it hard for Republicans to follow through. 

Medicaid expansion

The current law: For decades, being poor in America meant not having health insurance. Obamacare tried to change that by offering states billions of dollars to expand Medicaid, the government health plan for the poor.

That has helped millions of low-income Americans get health coverage over the last several years.

What’s at issue: Free federal money wasn’t enticing for all states.

To date, 19 states, all with Republican governors or legislatures, have rejected Medicaid expansion, saying Obamacare imposes too many rules.

What could change: Also unclear.

GOP repeal plans include rolling back the Medicaid expansion and slashing federal aid to states. And Trump has promised to let states redesign their programs, which might mean some start limiting benefits or requiring poor patients to pay more for their health coverage.

But many Republican governors have expanded Medicaid, making it more difficult for Republicans in Washington to cut federal funding.

Look for states to get more flexibility soon, though.

Medicare

The current law: This sacred cow was largely left out of Obamacare.

The law made relatively minor changes to the popular health plan for the elderly and disabled, though it did expand coverage of prescription drugs. That’s been popular with seniors.

What’s at issue: Not much, right now.

But many Republicans, including Trump’s pick to be health secretary, Rep. Tom Price (R-Ga.), have long dreamed of overhauling Medicare and changing it into a voucher program that gives seniors a set amount of money to shop for private health plans.

What could change: Medicare looks pretty safe.

Trump has said he won’t touch Medicare, and Senate Republicans haven’t shown much interest in a major Medicare fight. So action on Medicare seems less likely this year.

Taxes

The current law: Nothing is free, alas.

Obamacare’s architects cobbled together a mix of taxes to offset the cost of subsidizing insurance for tens of millions of low- and moderate-income Americans.

That has meant some new taxes on insurance companies and medical device makers (both of which, it was reasoned, were benefiting from getting new customers through the law).

Wealthy Americans are paying a bit more, too. Families making more than $250,000 a year have seen their Medicare payroll taxes increase slightly, thanks to Obamacare.

What’s at issue: If there’s one thing that Republicans seem to hate more than Obamacare, it’s taxes. 

What could change: It’s complicated.

Most leading GOP repeal plans ditch the taxes, and congressional rules will allow them to scrap the taxes with no Democratic votes.

But this one is causing headaches for Republicans, who are waking up to the realization that they may need some of this tax revenue if they want to fulfill their promise to protect the millions of people who depend on Obamacare.

That has prompted some GOP lawmakers to suggest that maybe they shouldn’t scrap the taxes after all.

Coverage for children up to age 26   

The current law: Obamacare’s “slacker mandate” requires health plans to allow adult children to remain on their parents’ plans.

What’s at issue: Not a lot. Mom and Dad might not like their college grad living in the basement, but it turns out most parents like knowing their children can have health coverage into their 20s. This has been one of the most popular parts of Obamacare.

What could change: Almost certainly nothing. Trump and congressional Republicans say they’ll keep this requirement.

noam.levey@latimes.com

Twitter: noamlevey

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