Amid in the election hubbub, the state health exchanges opened enrollment Nov. 1. As it stands, the fourth open enrollment will almost certainly be the last, especially for states using healthcare.gov.
What role uncertainty with the exchanges played in the election isn’t clear. The unsteadiness of the exchanges could have influenced voters in states like North Carolina and Arizona where the reduction in insurers and premium increases has been extreme.
With a Donald Trump win, the future of the exchanges is much more certain – and short. Those exchanges will go before a firing squad in January, when Trump and Republican Congress almost certainly repeal the six-year-old Affordable Care Act they have railed against since its passage.
For the exchange markets, the only guarantee about an Obamacare repeal is its messiness. The Affordable Care Act is going away, but how the exchanges, its most visible feature, face a complicated fate.
Will any states bother to keep their own health exchanges? Covered California or the Washington Health Plan Finder would be candidates. Massachusetts operated the exchange that served as the template for the ACA exchanges, but it spent tens of millions of dollars bringing that exchange into ACA compliance. Still, something will likely survive in the Bay State. As for other state exchanges, the repeal of the ACA would leave little incentive to operate such a marketplace.
There’s no guesswork for the federally facilitated and partnership exchanges - anything attached to healthcare.gov is headed for the dumpster. The neediest individuals covered through exchanges – the sicker, previously uninsurable people driving the cost trend – would likely land in some form of health risk pool, a central provision of the few Republic reform proposals circulated in recent years.
The real chaos of ending the exchanges lies in the individual market. Without subsidies or an individual mandate, the individual market will revert to its old model, bringing back the old days of sky-high premiums and pre-existing condition denials.
That said, open enrollment will roll into 2017. The Department of Health and Humana Services can’t simply pull the plug on open enrollment. Suddenly ending Medicaid expansion or shutting down the exchanges would create chaos in the market.
The big question is what will happen during open enrollment. People will still buy plans or will they? Will enrollment lag because an ACA repeal looms early in the Trump administration? Will people rush to buy coverage now knowing that they will not have it once the repeal goes into effect so they can use healthcare while they still can? Any of those scenarios is possible.
If a Republican ACA replacement excludes an individual mandate or prohibits denials for pre-existing conditions, the individual market again becomes a small piece of the health insurance pie. Outside of a few states, health exchanges stand to become a footnote to an ever-contentious law.
For more market access insights, follow Bill Melville on Twitter: @BillMelvilleDRG
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