America observed two national events last week. On Wednesday, North Carolinians woke up to news that Donald Trump had been elected President and that the outcome of the gubernatorial race would take some time to be determined. These are big changes, and I am starting to sort out how events in Washington and Raleigh will eventually impact my patients and the care that I may – or may not – be able to provide.
President-elect Trump has pledged to repeal the Affordable Care Act (ACA), or Obamacare, on his first day in office, however the six-year law is so established that a total dismantling is unlikely. Since the Trump campaign did not articulate a comprehensive health care plan, the new administration will rely heavily on Speaker Paul Ryan’s approach to cover some of the 20 million previously uninsured individuals who gained health insurance under the ACA.
Speaker Ryan’s plan calls for using block grants for Medicaid, the federal-state program which insures low-income citizens. This policy would seek to reduce federal regulatory restraints and promote flexibility and innovation at the state level. Fiscally, in place of the current federal matching program, Medicaid would move to a lump-sum payment transfer to states. Governor McCrory has opposed expanding Medicaid and this change would end the current ACA conversation around expansion.
A few days after the election, I was in the audience for a ceremony at UNC Health Care that honored our veterans. There were several speeches that afternoon and I was taken with one elderly veteran who was reticent about his service to our country, but was effusive in his thanks for the care he had received at our hospital. An earlier speaker had noted that North Carolina was one of the states with a large military presence. That evening I received a report from the Urban Institute and Robert Wood Johnson Foundation that examined the impact of the ACA on health insurance coverage for nonelderly veterans.
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The report found that between 2013 and 2015, the uninsurance rate for nonelderly veterans fell by an estimated 42 percent, declining from 11.9 perecent in 2013, to 8.5 percent in 2014, and to 6.8 percent in 2015. Over this time, veterans also reported fewer unmet health care needs, which suggests that greater coverage facilitated improved access to care. Of note, the uninsurance rate for veterans’ family members also declined over this period. The report made a recommendation “to further reduce coverage gaps for veterans and their family members under the ACA by increasing take-up among those eligible for Medicaid or marketplace subsidies, increasing enrollment in Department of Veterans Affairs care, and expanding Medicaid.”
The expansion of Medicaid through the ACA will no longer be an option in the Trump administration, a change that will lead to tremendous uncertainty as to what is in store for financially challenged patients. The federal government may increasingly look to a mechanism that allows states to have greater latitude in developing and implementing Medicaid programs. In North Carolina, Pat McCrory and Roy Cooper have expressed very different viewpoints on Medicaid expansion and their respective administrations will need to come up with policies and programs that ensure quality, affordable health insurance coverage for our most vulnerable citizens. The outcome of the governor’s election is undergoing a process of adjudication and a delayed resolution will only further the uncertainty for our patients.
Timothy Daaleman is a professor of family medicine and medical director of the Physician Assistant Program at the University of North Carolina at Chapel Hill