President-elect Donald Trump‘s intention to repeal and replace the federal Affordable Care Act could affect New York’s budget, to the tune of at least $850 million a year.
Billions more are at stake if a Trump administration and Republican-led Congress stop funding the expansion of Medicaid under the 2010 law, the signature health policy of President Barack Obama known as Obamacare.
Other Republican reforms could impact what New Yorkers pay for health insurance, whether they are individuals buying policies on the state’s Obamacare website, NY State of Health, or workers who get coverage through their employers.
A full repeal of the law may not be that easy, at least under current congressional rules, but changes that affect the federal budget could be made through the reconciliation process. Republicans have already tried to alter the law through that method, but have had their bills vetoed by President Obama. President-elect Trump would likely sign off on such measures, said Richard Nathan, who directs the ACA Implementation Research Network at the Rockefeller Institute of Governmentin Albany.
At a minimum, the state would lose a large portion of the estimated $850 million in federal assistance for offering what in New York is called the Essential Plan, according to state Assembly Health Committee Chair Richard Gottfried, D-Manhattan. The Essential Plan offers health coverage with no deductible for $20 a month to low income New Yorkers who do not qualify for Medicaid.
The largest group of Essential Plan beneficiaries were 250,000 legal immigrants who are not citizens and not eligible for Medicaid under federal rules, Gottfried said. Before the option of offering the Essential Plan, New York paid 100 percent of the premium costs for these residents, as a 2001 court ruling determined was required by the state constitution.
“We would either have to find revenue or cut something,” Gottfried said. “Cutting those 250,000 people off of Medicaid is not really an option because they are covered because of a Court of Appeals decision.”
New York also benefited from the expansion of Medicaid through Obamacare, Gottfried said. Because the state already allowed higher income limits for Medicaid recipients, the increase in enrollment was not as great as for some other states. But the federal government kicked in 90 percent of the premium cost, rather than the 50 percent it had been paying.
A full repeal of the law would eliminate mandates that health insurers cover Americans regardless of pre-existing medical conditions and allow adult children to stay on their parents policies until age 26. If accomplished, these would have little impact in New York, experts said. The state required coverage for residents with pre-existing conditions before the federal law was passed, Gottfried said. And adults could stay on their parents’ policies, though not until age 26, according to Nathan.
Whether repeal is even possible is questionable. Nathan said it would require 60 Senate votes — more than the slim margin won by Republicans — to get by congressional filibuster rules. But Gottfried said a new Congress would have the ability to change that rule at the beginning of its session in January.
Still, a Trump administration could use administrative orders to change the law, just as the Obama administration did to make fixes to the law, Nathan said.
“Under the blankets, there are a lot of things you can do administratively,” he said.
Other changes to Obamacare could affect coverage and premium rates for all New Yorkers, not just those plans offered through the state exchange, NY State of Health. A full repeal would eliminate requirements that insurers provide certain types of coverage, such as for prescriptions and mental health services, on all health policies. That would make it tougher to compare plans and reduce some Americans’ coverage. But it could also reduce premium costs by allowing insurance companies to offer policies with different levels of coverage, said Leslie Moran of the New York Health Plan Association, an insurance industry trade group.
What might happen to premiums for individual plans is unknown. The state could keep the exchange even without the federal law, said Wendy Weller of the University at Albany’s School of Public Health. But the mandate for all Americans to carry coverage would disappear, and it was that requirement that brought premiums down. Also gone would be federal tax credits that help people pay for individual coverage.
Almost 900,000 New Yorkers bought private health insurance through the exchange last year.
Trump has said he wants to allow the selling of individual insurance policies over state lines, to increase competition and in theory reduce premium costs. Dr. Charles Rothberg, president of the Medical Society of the State of New York, said that worried him, however. It would take away state regulators’ power to rein in premium increases and make sure New York patients are fairly insured, he said.
“I think our regulators protect consumers well,” Rothberg said.
