“If you're an insurance executive, you are extremely worried right now,” Laszewski said. “So many healthy people are not going to buy insurance waiting for the promise of the Republican plan.”
Medicaid faces a similarly precarious position. Garthwaite said Medicaid expansion enrollees who may return to the ranks of the uninsured will still get necessary care at hospitals, but hospitals will bear the cost of that in the form of higher uncompensated care.
Republicans have championed privatizing Medicaid. Congress and Trump will give states more control over how to design Medicaid benefits, but private managed-care companies won't be left out of the equation.
“I think Republicans are going to be very cost-conscious,” Molina said. Noting that Medicaid expansion is actually less expensive than premium subsidies, he ventured, “I think we will see expansion of Medicaid up to 200% of poverty.” The ACA expanded Medicaid eligibility up to 138% of the federal poverty level.
House Speaker Paul Ryan and congressional Republicans could press hard to transform Medicare into a premium-support, or voucher, program. Under that model, Medicare beneficiaries receive a fixed amount of money from the federal government, and they use those payments to get their care from either traditional Medicare or private plans. A move away from defined benefits and toward narrower provider networks would potentially expose seniors to higher out-of-pocket costs.
Many insurers have invested heavily in the private version of Medicare, called Medicare Advantage, and view it as a lucrative business line. Medicare Advantage will be “the solution to entitlement reform around health benefits,” Aetna CEO Mark Bertolini said at an investor conference in March.
But the goals of Medicare vouchers don't line up with why Medicare Advantage has grown so much. Premium support will cap how much the government will pay for coverage and presumably requires beneficiaries to pay more if they want a particular health plan. That would either erode the number of health plan options with no premiums, potentially dampening enrollment, or it would force Medicare to pay insurance companies much less, potentially dampening their profits and interest in participating.
Higher enrollment would be good for the plans, said Richard Lieberman, chief data scientist at consulting firm Mile High Healthcare Analytics. But Lieberman also said Republicans would probably cut the Medicare budget along the way.
Ignagni said the fundamental tenets of health insurance—quality, affordability and access—won't change with a new administration. Her company and others will be involved in the next round of reform.
“We do a lot of work with our elected officials, both state as well as federal,” said Ignagni, who led AHIP for more than two decades before she left for EmblemHealth last year. “We will continue to do that, absolutely.”