President Trump may turn out to be right on this one.
On Friday, the president said the Affordable Care Act (ACA), also known as Obamacare, was going to “explode.”
He repeated that prediction in a tweet on Saturday.
And on Monday, his press secretary, Sean Spicer, reiterated the expectation, saying Obamacare was “dying on its own.”
They made the statements in response to the failure of Republican leaders in the House of Representatives last week to approve a plan to “replace and repeal” Obamacare.
Experts interviewed by Healthline said the ACA may indeed start to unravel later this year.
In part, they said, because Obamacare was headed for trouble anyway.
And it’s also because the Trump administration might not do much to help the healthcare system and, in fact, can do things to help push it over the cliff even sooner.
So, what happens if the ACA does collapse?
“It’s going to be chaos,” Kurt Mosley, vice president of strategic alliances at Merritt Hawkins health consultants, told Healthline. “There has to be some kind of life support for the current system until a new plan is passed.”
Twila Brase, president of the Citizens’ Council for Health Freedom, had a similar but slightly less pessimistic view.
“I think Obamacare as we know it will implode,” Brase told Healthline. “However, that doesn’t mean the health system will implode.”
Will they sabotage?
Obamacare was facing a number of obstacles already this year.
The first was that several large insurance firms, among them UnitedHealthcare, had already significantly cut back on their participation in the state marketplaces that sell health insurance under the auspices of the ACA.
That has left about one-third of the counties in the United States with only one insurer in these marketplaces, according to a Kaiser Family Foundation report.
The ACA system is also having trouble getting younger, healthier people to sign up. The tax penalties imposed on people who don’t have health insurance haven’t been high enough to motivate those younger folks to enroll.
Despite these problems, Ron Pollack, the executive director of Families USA, said Obamacare will remain healthy if it is allowed to move forward unimpeded.
“I think [the implosion] is purely wishful thinking on the part of the president,” Pollack told Healthline.
However, he acknowledged there are a number of things the White House can do to sabotage Obamacare.
“It really is a question of what is the intent of the administration,” said Pollack. “It’s hard not to take [the president’s comments] as a signal.”
One thing the White House has already done is relax enforcement of the tax penalties for people without insurance.
That is likely to encourage even fewer younger, healthier people to sign up. Without their participation, it’s difficult for insurance companies to balance the costs of insuring older participants and less healthy customers.
“Unless young people sign up for this, I don’t see how it works,” said Mosley.
The other thing the White House has already done is not promote the open enrollment periods.
In late January, the Trump administration pulled the ads for Obamacare a couple weeks before this year’s enrollment period ended.
In the end, 9.2 million Americans signed up for insurance plans on healthcare.gov, which serves 39 states. If state-run exchanges are included, Obamacare enrollment rises to 12 million. That’s still about half a million fewer enrollees than last year.
The Trump administration could decide to forgo advertisements for the entire 2018 enrollment period, which begins on Nov. 1.
“There won’t be as much pressure on people to sign up then,” Brase noted.
Other ways to sabotage
There are a number of other things the White House can do to help derail the ACA, if it chooses.
One is to cut the cost-sharing subsidies that help people pay the premiums on the insurance they purchase on the marketplaces.
That could be done in the upcoming budget process for the next fiscal year.
Mosley said that could send premiums to unaffordable levels, especially for people with chronic conditions.
“The cost would be out of reach for a lot of people,” Mosley said.
“That would discourage a lot of people from staying in the marketplace,” added Pollack.
The White House could also decide not to defend the ACA against lawsuits filed against it, something the Obama administration steadfastly did.
“There’s a new sheriff in town. They could decide they’re not going to do it,” said Mosley.
The experts said that would allow opponents to continue to chip away at the healthcare law.
There’s also the question of Medicaid expansion.
Since the ACA was enacted in 2010, 31 states and the District of Columbia have opted to expand Medicaid for low-income households and receive federal funds to help administer the program.
Mosley said a number of states were considering joining that expansion this year when it appeared Democrat Hillary Clinton was going to win the presidency.
However, with President Trump in the White House, he says that’s unlikely to happen.
“I think talk of anybody expanding is dead right now,” he said.
What to expect
If the worst case scenario arrives and Obamacare collapses at year’s end, what is the fallout?
The experts don’t paint a pretty picture.
“That could cause real problems,” said Pollack.
The experts see more people without insurance coverage and higher premiums for those who buy plans in the marketplace.
Mosley said more insurance companies might decide to walk away from the marketplaces. Others will simply stand on the sidelines to see what happens.
“They’ll have their finger in the wind,” he said.
Pollack adds that the 155 million Americans who have health insurance through their employers might also be impacted.
He said companies could decide to cut back on coverage or continue to offer plans with high deductibles and out-of-pocket expenses.
Brase, however, said there may be a silver lining in all this.
She said states may decide to take more control over their health insurance plans. They are being given more leeway on how they implement the ACA under the act’s Section 1332, which takes effect this year.
“They should be doing this anyway,” she said. “This could be the beginning of things heading in the right direction.”
Whatever happens, the experts agree that what the Trump administration does or doesn’t do will probably make or break Obamacare during the next year.
“I don’t believe Congress can do anything to prevent the implosion,” said Brase. “Whatever the administration does — that will be the difference.”