Plenty of changes could be coming to health care in the wake of Tuesday’s election.

By Rose Hoban

As pundits, politicians and pollsters work to decipher the electoral message sent by voters Tuesday, one of the biggest questions raised by the results – both nationally and in North Carolina – surrounds the future of the U.S. health care system.

President-elect Donald Trump made repeal and replacement of President Barack Obama’s signature Affordable Care Act one of the promises of his campaign, yet local political pundits on both sides of the aisle are wondering what that will actually mean.

“The dog has caught the car,” quipped Duke University health economist Don Taylor, Jr. He said that Republicans have wanted to repeal the ACA for as long as it’s been law, but he also said that, “they got what they claim they want, but they have no idea what to do next.”

Longtime Republican political strategist Carter Wrenn chuckled when he heard that analogy.

“At this point, you don’t know how this will evolve and what will be debated,” he agreed.

But after six years of implementation, with tens of millions of people who are either now covered under Medicaid or finally have access to affordable insurance plans, it’ll be hard to take those things away from voters, both men agreed.

“All you can conclude is, it’s coming but you don’t know what form it’s gonna come in,” Wrenn said.

Local idea

Clues to what form an Obamacare replacement might take can be found in the files of North Carolina Sen. Richard Burr (R), who, in 2014, proposed an alternative plan along with Sens. Orrin Hatch (UT) and Tom Coburn (OK).

An analysis of Burr’s Patient Choice, Affordability, Responsibility, and Empowerment Act  generated by the nonpartisan Center for Health and Economy, found several elements similar to parts of Obamacare, including insurance plans that include so-called narrow networks, where beneficiaries have access to a limited number of care providers in exchange for low prices, no lifetime limits on coverage and coverage for young people on their parents’ plans up to the age of 26.

But the plan differs from Obamacare in that folks with many medical issues will be grouped into high risk pools, people will receive tax subsidies to help pay for insurance, and the federal government will cap state funding for Medicaid.

Both Taylor and Wrenn were quick to point out this is only one plan out there, and there could be others.

“I think [Congress] will all agree with repealing Obamacare,” Wrenn said. “The question is once they have to put together a replacement, that’s going to be a lot more complex than it sounds.

“It can’t start to be put together until you know what you’ve got.”

Medicaid changes

One hope held by many North Carolinians was that post-election, the legislature would consider expanding the Medicaid program, as the Affordable Care Act allows.

Tuesday’s results could be interpreted as dashing those hopes, but some observers noted that more Republican-controlled states could actually embrace Medicaid expansion.

Check out our other stories on the implications of the election on NC health issues:

What the Election Could Mean for NC: Environmental Health

What the Election Could Mean for Older North Carolinians

“Since half the states have expanded, does that mean then that you don’t let the other states have the option?” asked former Health and Human Services Secretary Lanier Cansler, a Republican who served under Democratic Gov. Bev Perdue.

“It’s going to be politically difficult to have given this… made this available to millions of people and then to say, ‘We’ve changed our minds, you don’t get this any more?’” he said.

“It’s not a certainty this eliminates the possibility for expansion.”

Advocates say they’ll keep pushing.

“We have people without access to health insurance and we need an N.C. solution to the problem,” emailed longtime advocate Peg O’Connell, who has been working on expanding rural access to care. “We will be looking to work with our state lawmakers to assess where we are and how N.C. can address the needs of our citizens. Access to healthcare is an issue that needs our attention.”

And one new Republican member of the General Assembly, Donna White, said there’s a real case to be made for some form of expansion. White, a Johnston County home health nurse for more than a decade, works with many folks who lack access to care.

“I do feel like I could be a strong voice,” White said. “I’ve lived it, I think I have some good experience I can bring to the table. Sometimes hearing real stories helps people understand what needs to be done and helps us negotiate ways to get there.”

The other big change coming to Medicaid is the legislature’s plan for converting the program from a one where providers are paid on a fee-for-service basis to one where managed care companies pay doctors to provide for all of a patient’s needs in exchange for a set fee.

That’s not too different from what Burr proposes in his health reform plan, where Medicaid would be converted into a block grant program, creating a set amount of money given to states to spend as they see fit.

But in the short run, North Carolina’s application to federal regulators to overhaul Medicaid is likely to slow down, said Cansler.

“It’s a little uncharted,” he said.

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