UNC prof: Uncertainty, instability to follow ACA repeal

Often referred to as "Obamacare," the signature legislation of former President Barack Obama's administration ushered in free preventive care, from annual physicals to free mammograms and colonoscopies, coverage for those with pre-existing conditions and children remaining on their parents' health plans until age 26.

The law also led to soaring insurance premiums as insurers sought to make up for losing millions of dollars because they were paying for more coverage of more people.

"Health care is expensive because it's necessary," said Dr. Cedric Bright, assistant dean of the University of North Carolina School of Medicine and a past president of the National Medical Association.

Bright, who also is a primary care physician and internist at UNC Health Care, said his biggest concern with President Donald Trump's and congressional Republicans' plan to repeal and replace the ACA is people losing health coverage.

"We have over 500,000 people in North Carolina benefiting from the Affordable Care Act. We would hate to see the people fall off and us being the safety-net hospital," he said.

Hours after he took office last Friday, Trump signed an executive order that gives federal agencies the authority to grant waivers, exemptions and delays of provisions in the ACA that would impose costs on states or individuals. The order also directs agencies to stop issuing regulations that would expand the health care law's reach.

The order appears to be the first step toward scrapping the so-called individual mandate, the provision of the ACA that required people to have health insurance or pay a tax penalty.

The mandate was included in the law to prevent people from gaming the system by obtaining coverage only when they developed serious health conditions. But the penalty hasn't proved enough of a threat to get young, healthy people to sign up for coverage and pay into the system, meaning coverage has become more expensive for everyone else as insurers were weighed down by paying for treatment of older, sicker people.

"If you go ahead and take away that individual mandate, you will probably make that population that signs up for coverage even sicker," said Dr. Jonathan Oberlander, a professor of social medicine and health policy and management at the UNC School of Medicine. "So, Republicans in the Trump administration have to find a substitute for that penalty, a different way to get healthy people to sign up for coverage."

Trump has promised that no one's insurance coverage will be taken away and that people covered under the ACA can expect to have great health care that's less expensive. But no replacement plan has emerged on Capitol Hill, although congressional Republicans have put forth a number of ideas.

"We're about to enter what I would call an abyss," Oberlander said. "We're going to take a leap into this period of health policy purgatory where the ACA is repealed, yet we don't know what's going to replace it. Uncertainty and instability that's going to be the rule."