Longtime health reporter Julie Rovner is chief Washington correspondent for Kaiser Health News, a nonprofit news service providing in-depth coverage of health care policy and politics. Before joining KHN, Rovner was a health reporter for 16 years at NPR, where she helped lead coverage of the enactment and implementation of the Affordable Care Act.
Rovner was in Kansas City last week to participate in a panel discussion presented by American Public Square, a Kansas City-based nonprofit that arranges public forums on health, education, faith and other topics, on the future of the ACA. Afterward, she sat down with KCUR editor and reporter Dan Margolies to talk about what the future holds for President Barack Obama's signature domestic achievement. The interview has been lightly edited for length and clarity.
The Affordable Care Act remains the law of the land despite attempts by the Republican- controlled Congress to repeal it. Care to predict what happens to it going forward?
It is completely unclear what's going to happen now. I'm sort of out of the prediction business. But I think one thing that's fair to say is that, yes, the Affordable Care Act still exists but it has definitely been weakened.
The repeal of the fines for people who don't have health insurance -- which doesn't take effect until 2019 -- is going to create a lot of uncertainty for insurers going forward. The Trump administration is trying to create new rules to allow new types of insurance policies that could theoretically sort of entice younger, healthier people out of the individual market of the exchanges, so that that would tend to run up premiums even more. Congress talks about wanting to stabilize the program but so far hasn't done anything.
So I mean we are sort of at a tipping point. It could go either way or really three ways: It could survive; I mean there was very, very strong enrollment this year. It could be completely undermined. Or it could just sort of continue to limp along.
As part of the tax overhaul Republicans passed in December, the individual mandate requiring people to have health insurance was repealed. What effect do you think that will have?
Well, right now its main effect is confusion because it is not gone for the people who are filing their taxes now for 2017. It in fact will not be gone next year for people who are filing their taxes for 2018. It disappears on Jan. 1, 2019. So the biggest impact will be on insurers who are deciding in the next few months whether they want to offer insurance for 2019 and how much they want to charge.
Now, this is a point where we get to say we are only talking about the individual insurance market here. We're talking maybe 19-20 million people. The vast majority of people get their insurance through their employers or through the government – Medicare, Medicaid, VA programs. They are not impacted by this. It is purely for people who buy their own insurance because they don't have any other access.
The Trump administration recently told states that they could impose work requirements as a condition of Medicaid eligibility. The Centers for Medicare and Medicaid Services has already approved a work requirement waiver in Kentucky, and nine other states, including Kansas, have submitted proposals to CMS. How do you see this playing out?
This is a really big change for the Medicaid program. There have been work requirements in welfare before, but cash welfare is something that you can live on. So there was at least some theory that if you got a job, you would earn more than your cash welfare. Medicaid is health insurance, it's not something you can live on. And studies have shown the vast majority of people who get Medicaid are either already working – many of them are low-wage workers – or they can't work because they're disabled or can only work limited periods because they're taking care of somebody else who is sick.
So it's a very small number of people who aren't working who could be working. On the other hand, a lot of analysts say that the imposition of work requirements is likely to end up with people not having insurance because they can't run the bureaucratic traps that will be necessary to keep their insurance, even if they are working.
Idaho announced recently that it will allow insurers to sell plans that don't meet ACA requirements. So what happens to the ACA if the Trump administration says that's OK?
Well, the Trump administration wouldn't necessarily say it's OK. The question is whether the Trump administration will step in and say this is against the law. One esteemed law professor called this “crazy pants illegal.” It's pretty clear that Idaho knows what it's doing and it's just sort of betting that no one will stop them. And this is a really big question, because if Idaho kind of gets away with it, other states might also.
The big question mark, though, is whether insurers will actually want to offer these kinds of plans because in the case that the administration does come in and says, “No, you can't do this,” there are big fines on the books associated with doing it. So it's possible that Idaho is going to do this and nobody's going to come and play.
If I can ask you to peer into your crystal ball, what does the U.S. health care system look like, say, 10 years from now?
Wow. Well, one of the things that's important is that in 10 years the leading edge of the baby boomers will be reaching their high health cost years. You know, there's been a whole lot of debate about the 19 million people who buy their own insurance and not very much debate about the 55 million people on Medicare. I think Medicare by necessity is going to come back as an issue.
The other big issue that just hasn't been addressed in the mix is long-term care, which Medicare doesn't cover (and) which Medicaid does. But it's very expensive. Also a dormant debate that's going to come back to smack us in the face in the fairly near future.
Dan Margolies is a senior reporter and editor for KCUR. You can reach him on Twitter @DanMargolies.