It’s Not Too Late to Change your Medicare Advantage plan

As a result of new federal legislation, subscribers of Medicare Advantage Plans will have three additional months (January-March each year) to change their plan. 

Why would you want to change plans now?

Some reasons could include:

  •  You missed the Annual Fall Open Enrollment period (October 15-December 7)
  • You didn’t realize your plan doesn’t include your medications, preferred doctors, hospitals, pharmacies, etc.
  • Your health condition has changed and you want better coverage.
  • Your financial situation has changed and you can’t afford your current plan.
  • You or your relative didn’t understand the limitations, cost or consequences of their current plan

Normally, you wouldn’t be able to change plans for these reason during the calendar year, except in special circumstances. However, now you will have 3 additional months to make a change each year.

To be eligible to make a change, you must currently be a subscriber of a Medicare Advantage plan (as opposed to being a subscriber to Original Medicare).

What are Some Permitted Changes?

  • You can change from one Medicare Advantage plan to another (from the same or a different insurer)
  • You can select a new plan that either increases or decreases your coverage and/or cost.
  • You can terminate your Medicare Advantage plan and switch to Original Medicare and buy (or not buy), a stand-alone Prescription Drug Plan (PDP).
  • In some states, like New York, you can also choose to purchase a Medicare Supplemental (Medigap) plan for added coverage to Original Medicare, with or without purchasing a PDP.

Is there anyone who can help you look at your options and their consequences?

Yes, there are a number of free independent resource people that don’t receive any sales compensation that can help you understand these complex issues.  They include:

SHIP connects you with local individual and group information/assistance regarding Medicare issues and questions.

National Helpline: 800-333-4114

MRC helps people with Medicare understand their rights and benefits, and navigate the Medicare system.

What to Look for in a Medicare Prescription Drug Plan



  • Approximately 43 million or 72% of the people on Medicare are enrolled in Medicare-approved Prescription Drug Plans (PDP)
  • If you have Original Medicare (with or without) a Medigap plan, you likely need a PDP to have drug coverage and avoid a future penalty.
  • You need to have a PDP from the month that you were initially eligible for Medicare, or 2006 when PDPs were first established.
  • Most Medicare Advantage Plans include prescription drug coverage along with medical coverage.
  • There are no annual maximum out-of-pocket prescription drug expenses for either Medicare Advantage or stand-alone PDPs. Original Medicare & Medigap plans do not cover prescription drug expenses.
  • Medicare-approved stand-alone PDPs are sold primarily by large, for-profit insurers such as Aetna, Cigna, CVS, Humana, and United HealthCare. Medicare enters into contracts with private insurers to provide PDPs that meet specific requirements. In return, the private insurers receive over $83 billion a year in taxpayer subsidies for PDPs.
  • Private insurers are also allowed to charge subscribers plan premiums, deductibles and co-pays/co-insurance for medications. They can also exclude specific drugs from their formulary, establish restrictions: such as requiring prior insurer authorization, limit medication quantities and require that subscribers take lower-cost drugs before higher-cost drugs.
  • Each insurer establishes their own drug classifications into pricing tiers and there are significant differences among PDPs regarding the drugs that are excluded/included and the premiums, deductibles, co-pays/coinsurance that subscribers are required to pay.
  • Although PDPs are not allowed to deny coverage or charge higher premiums to subscribers with pre-existing conditions and chronic diseases, insurers have latitude in establishing restrictions and subscriber charges.
  • Unlike the rest of the developed world, in the USA there is no public insurance for medications or government negotiation of drug prices with the exception of the VA. As a result, the cost of medications in the United States, to treat millions of Americans with life-threating diseases such as diabetes, cancers, multiple sclerosis, Hepatitis B, inflammatory diseases, respiratory diseases, organ transplants are the highest in the world. The cost of medications has become a huge burden on taxpayers; federal, state and local governments; employers; patients and families. This results in more costly health care with poorer outcomes, increases in disability, reduced work productivity and becomes a major cause of personal bankruptcies in the USA.
  • Medicare Quality Star Ratings -Medicare uses a Quality Star Rating System to measure how well Medicare Advantage and Part D plans perform. Medicare scores how well plans perform annually in several categories including quality of care and customer service. Ratings range from Poor (1 star), Below Average (2 Stars), Average (3 Stars), Above Average (4 Stars) and Excellent (5 Stars). Details of specific PDP and Medicare Advantage plan ratings are published on

A review of major insurers and their 23 PDPs in Upstate New York including plans by Aetna, Cigna, Express Scripts, Humana, SilverScripts, United HealthCare (UHC)  and WellCare reveal the following observations.

  • Each insurer generally offers 3 plans with different premiums and deductibles. Premiums range from $15.50 a month with a $415 deductible (WellCare Value Script) to $92.50/mo. with a $350 deductible (Express Scripts Medicare Choice)
  • Seven plans have no deductibles with premiums ranging from $39.70/mo.                    (SilverScriptsChoice) to $80./mo.(Humana Enhanced & SilverScript Allure).
  • The Medicare Quality Star ratings of plans vary from 3.5/5 Stars ( 3 SilverScript plans & UHC AARP Preferred) to low-rated plans (EnvisionRx Plus 1.5/5 & three Cigna plans 2/5 Stars). Other plans offered by Aetna, Humana, WellCare, and two UHC plans each received a 3 Star rating.
  • All insurers have developed strong financial disincentives for subscribers who use “non-preferred” brand name and generic medications by establishing medication exclusions, deductibles and up to 50% co-insurance for Tier 4 drugs.
  • Many insurers also charge higher prices for standard pharmacies and 30-day supplies with lower prices for “preferred” retail and mail-order pharmacies. However, many consumers and health care providers are unaware of what pharmacies are preferred and the cost differences that can be substantial.


  • There are significant differences among insurers in the number of brand name and specialty drugs that are excluded in their formularies. Some diseases including rheumatoid arthritis, multiple sclerosis, diabetes and various neurological, cardiovascular, inflammatory, autoimmune and respiratory diseases have higher-cost Tier 4 & 5 medications and more excluded drugs than other conditions. This creates major conflicts among insurers, physicians and patients.
  • The co-insurance rate for Tier 4 “non-preferred generic and brand” medications in many cases is double the co-insurance rate for more costly Tier 5 specialty drugs. Many plans exclude specific medications or place them in Tier 4, that are used to treat common conditions such as diabetes, inflammatory, autoimmune and cardiovascular diseases in favor of other specific drugs sold by competitor drug companies. Insurers have increased “excluded medications” by 160% in the past 4 years and boast about saving billions of dollars each year by reducing access to treatment and raising patient expenses.

Differences in Subscribers Satisfaction with Plans

One dimension of Medicare’s quality ratings is the analysis of subscribers’ level of satisfaction with their specific PDP or Medicare Advantage plan. Medicare looks at a number of areas including quality of services and customer service. Two area that are important to look at include turnover rates (the percentage of subscribers who leave the plan) and the major reasons for leaving. The following analysis focuses on 23 PDP plans sold in Upstate New York.


  • SilverScript’s three plans: Choice ($37.90), Plus ($73.80) and Alure ($80/mo.) stand out from other plans in that they all have a 3.5/5 Star rating; none have deductibles and they have a low subscriber turnover rate of 6%  but 34% of subscribers who left complained about costs.


  • UHC AARP 3.5 Star Preferred plan ($77.70) with no deductible) and had a low 7% turnover rate but 56% of the people who left, complained about the high costs.
  • UHC other two plans: AARP Saver Plus ($59.90/mo. + a $415 deductible) and AARP Walgreens ($28.10/mo. + $415 a deductible) have a lower, 3 Star rating and 15% turnover rate with 45% of subscribers who left, complained about costs.


  • Humana‘s three plans earned 3 star Medicare ratings including its Walmart Rx ($35.70/mo.+ $415 deductible)Preferred Rx ($37.40/mo. + $415 deductible) and Enhanced ($80.50/mo. with no deductible. The plans all had 11% turnover and 31% subscriber complaints regarding costs.


  • WellCare’s plans all were rated 3 stars rated and ranged in price from Value Script ($15.50/mo.+ $415 deductible), Classic ($37.90/mo.+ $415 deductible) and Extra ($81.50/mo. with no deductible) all had consistent turnover rates of 13% and 33% complaints about costs.


  • Aetna’s 3 star Select ($17.70/mo. + $330 deductible) had 12% turnover and 33% complaints about costs while their 3-star Value Plus plan ($58.80/mo. with no deductible) had 24% turnover and 53% complaints about costs.

In summary, in considering PDPs it is important to confirm if the plans:

  • Include your medications and at what costs
  • Have a deductible expense on your drugs;
  • Have restrictions on access to your medications,
  • Have preferred retail and mail-order pharmacies,
  • Have high subscriber turnover and/or have other significant negative issues identified by subscribers and/or Medicare.

And finally, what is the total annual cost to receive your medications from each plan and the comparative differences in quality, costs and benefits.


Free resources are available to help you in comparing costs among plans. These include:

Medicare Plan Finder

Provides detailed information from Medicare to compare Quality Star ratings, your estimated annual and monthly cost (premiums, deductibles, co-pays/co-insurance) for your specific medications and pharmacies among available Prescription Drug Plans and Medicare Advantage Plans sold in your community.


State Health Insurance Assistance Program

Provides free personal and group information/assistance with Medicare issues and questions.



Helps people with Medicare understand their rights and benefits, and navigate the Medicare system


Congressional Budget Office, 2018 reports

Kaiser Family Foundation, 2018 Data Briefs and Fact Sheets

Medicare Rights Center

Medicare Trust Fund Board of Trustees, 2018 Annual Report

The Doctor-Patient Rights Project



Six Things to Know about Your Medicare Advantage plan’s Drug Coverage & Costs


  1. Significant taxpayer subsidies are given to private health insurers through Medicare to provide prescription drug plans (Medicare Part D) to eligible seniors and disabled individuals.
  2. There is no annual limit on your out-of-pocket prescription drug expenses in Medicare Advantage plans.
  3. Private insurers control their drug expenses by restricting their subscribers’ access to medications through the design of their formularies including what medications are excluded, requiring prior insurer authorization, limiting quantities, requiring subscribers to take lower cost drugs before higher cost drugs and establishing different drug price tiers, annual deductibles, co-pays and coinsurance.
  4. There are significant differences among Medicare Advantage plans including the drugs they include and the premiums, deductibles, co-pays and coinsurance that subscribers are required to pay.
  5. Although Medicare Advantage plans are not allowed to deny coverage or charge higher premiums to people with pre-existing conditions and chronic diseases, prescription drug policies that insurers establish provides a clear message of who they want as subscribers.
  6. The cost of medications to treat millions of Americans with life-threating diseases such as diabetes, multiple sclerosis, Hepatitis B, inflammatory diseases, respiratory diseases, various cancers, organ transplants are all extremely high and most require ongoing medications for life.


Medicare DrugCost

A review of four major Medicare Advantage insurers in Upstate New York including national for-profits: Aetna and United HealthCare and regional non-profits: MVP and Excellus Blue Cross revealed the following observations.

  • All insurers target enrolling healthy seniors and provide incentives of low or no monthly premiums along with gym memberships.
  • All insurers have developed disincentives for subscribers who use “non-preferred” brand name and generic medications by using medication exclusions, deductibles and higher drug co-pays and co-insurance.
  • There are significant differences among insurers in the number of brand name and specialty drugs that they exclude in their formulary.
  • Subscriber co-insurance for Tier 5 specialty drugs can be as high as 33% of the insurers published cost and 100% for drugs that have been excluded from the plan’s formulary. This can result in thousands of dollars of out-of-pocket expenses.

In summary, you may have insurance for your prescription drugs in your Medicare Advantage plan, but you may not have coverage or the ability to pay for your critically needed medications for life-sustaining treatment.

As result,  it is very important that you that you educate yourself and confirm that the Medicare Advantage plans that you considering meet your needs and budget during this Medicare open enrollment period that ends, December 7th.

How to Avoid Costly Mistakes in Choosing a Medicare Plan


Medicare’s annual open enrollment runs from October 15th to December 7th. During this time, Medicare subscribers can join or change plans including:

  • Medicare Advantage plans:
  • Return to the original Medicare coverage
  • Medicare Supplemental (Medigap) plans;
  • Part D Prescription Drug plan

It is very important to make an informed choice of the best insurance plan for your medical needs, preferences, and budget. A bad choice can cost you thousands of dollars and prevent you from receiving services that you need from your preferred providers.

Medicare Insurance Options for Seniors


Original Medicare is the government-run health insurance for seniors and disabled people that use private doctors, hospitals and other healthcare providers.

By comparison, Medicare Advantage (MA) plans that often include a prescription drug plan, stand-alone Prescription Drug plans (PDP) that are used with original Medicare and Medigap (Supplemental) plans are all sold by private insurance companies that are subsidized and regulated by Medicare.

These plans are offered by a variety of large for-profits (eg. United Healthcare, Humana, Aetna), national non-profit organizations such as Blue Cross and many regional non-profit insurers.

In addition, some seniors are eligible to receive their health insurance through their current or former employer.  And most Veterans are eligible to receive their health care and medications through the Veterans Administration.

Common Problems to Avoid

Your plan doesn’t include your preferred service providers.

If you don’t verify that your health care providers have a network contract with the insurer that you are considering, you could be facing huge bills. You could be responsible for paying the full cost of expensive services from health care providers or declined service.

Out-of-Network does not mean out of your area. Your preferred health care provider could be next door, but may not have a contract with your insurance company.

Be especially cautious of PPO plans, often sold by national insurers, that lead you to believe that you can go to any doctor anywhere. This is not accurate. Many times national insurers have not developed local provider networks or formal contracts. They often pay commissions to insurance agents to sell policies but do not have local staff to resolve provider and subscriber issues and concerns. These are often handled by central call centers.

The fine print in PPO plan documents includes this disclaimer: “Out-of-Network/non-contracted providers are under no obligation to treat plan members, except in emergencies”

This means that while you may have insurance, you may not be able to find a provider that accepts your plan, for a variety of reasons.

Didn’t Anticipate High Deductibles and Out-of-Network Costs

Some plans, such as the Aetna Elite PPO are advertised as a $0 premium plan, however you need to pay the first $1,000 for many medical services. In other PPO plans, you could pay up to 40% for “out-of-network” services.

In addition, many plans require up to a $400 annual deductible for Tier 3-5 drugs that do not have a generic equivalent. Consumers need to be aware that each insurer decides what drugs to include and exclude, and what they will charge subscribers. Drug prices can also vary by the pharmacy that you choose and if you choose a 90 day mail-order supply versus a more costly monthly supply.

In considering plans, you should not focus solely on the advertised premium cost, but rather your medical, drug, out-of-network needs and your projected out-of-pocket expenses including premiums, deductibles, co-pays, out-of-network charges and drug costs.unknown-1 provides a very good “plan finder” that helps you analyze medical & drug expenses among various plan options that are available where you live.



Didn’t Consider Medigap Plans for High Medical Expenses and Maximum Choices

Many Medicare Advantage HMO plans have little or no out-of-network coverage and you may have to pay up to 40% of the costs. If you have serious medical conditions that require costly tests, hospitalization, surgery and intensive outpatient treatment such as cancer, heart disease, renal disease and/or you would like the freedom to select specialty providers outside of your plan’s network, you’ll need good coverage at an affordable price. “Original Medicare” has no limit on your annnual expenses. And, Medicare Advantage plans have a high annual maximum out-of-pocket limit of $6,700 but there is an alternative–Medigap plans.

As a general guide, if your projected annual out-of-pocket medical expenses (premiums, deductibles & co-pays – excluding your prescription drug expenses) exceeds $3,000/yr. and/or you want Medicare coverage across the country, you should explore a Medigap plan.

Medigap plans provide supplemental coverage to original Medicare and pays for deductibles and copays. All healthcare providers who participate in Medicare across the country are included and there are no out-of-network exclusions or surcharges.

Medigap plans are regulated by each state and you can receive information on the availability of plans and their premiums by contacting your state insurance department

Didn’t Think I Needed or Understood Differences in Prescription Drug Plansmed prices

Most Medicare Advantage plans include prescription drug (Part D) coverage. However, if you have “Original Medicare” with/or without a Medigap plan, you will also need to purchase a prescription drug plan (Part D) unless you have an approved employer drug plan or receive your medications from the VA.

If you don’t have a an approved drug plan and you want to purchase one at a later date, you are likely to be subject to a late enrollment penalty.

Part D plans are sold by private insurance companies. The premium cost of plans varies widely from $15 to $90 a month with a national average premium of $40/month. In addition, many plans have annual deductibles that can add up to $415 in your expenses

It is important to check plans that you are considering to confirm that the medications that you need are included; if there is an annual deductible and what your co-pays and total annual expenses will be before enrolling in a plan. has a good planfinder that compares the different cost of the various Part D plans based on the medications that you use and where you live.

Didn’t Expect a Medicare Enrollment Penalties


Medicare rules require that if you want to receive Medicare benefits, you need to enroll and pay your Medicare Part B (outpatient) and Part D (prescriptions) premiums when you are first eligible. There are a few penalty exceptions, for example, if you receive creditable medical and drug insurance from you or your spouse’s employer, if you receive your medications from the VA.

Medicare penalties can be significant. The Part B (outpatient care) late enrollment penalty is 10% for each year, from the date of your initial Part B eligibility. The Part D (prescription drugs) penalty is 1% for each month from when you were initially eligible, or June 2006, the start of the program. There are a few circumstances when penalties can be reduced or eliminated.

The Importance of Having a Good Medicare Plan

Selecting the best plan for you or your family member is a very important responsibility since the consequences can be significant, both to your pocketbook and your ability to receive needed health care from your preferred providers.

Investing time in planning and seeking objective advice in selecting a plan, can save you a lot of time, money and headaches. The following is a list of free resources that are available to help you.



Social Security Administration,, 800-772-1213

The Social Security Administration is the agency that you need to contact to apply for your Social Security benefits and enroll in Medicare Part B and D., In addition, you can be screened for eligibility (income and resources) and apply for “Extra Help” with your Part D premium and cost of your medications


Medicare: – 800-633-4227

An excellent resource with Medicare information and specific help in comparing Medicare Advantage and Prescription Drug Plans in your area.


State Health Insurance Assistance Program  SHIP 877-839-2675

Medicare contracts with states, counties and nonprofit organizations to provide individuals with personalized education, support, and assistance with Medicare.

These free services include comparative plan information, eligibility for financial assistance as well as help with selecting a Medicare plan, enrolling, and resolving problems.


Partnership for Prescription Assistance

 This is an online information resource tool. You can learn about assistance programs that are available for specific medications, along with the eligibility criteria and program applications.


Medicare Rights Center, , Helpline: 800-333-4114

The Medicare Rights Center is a national, nonprofit consumer service organization that works to ensure access to affordable health care for older adults and people with disabilities through counseling and advocacy, educational programs and public policy initiatives.


This article was updated in October 2018 from a 2017 post

10 Things You Didn’t Know about EPIC -NYS’s Prescription Assistance Program for Seniors


NYS, like 15 other states, has a wonderful prescription assistance program for seniors called EPIC. It can make a huge difference for seniors, if they only knew about it.

10  very important things that you probably never knew about EPIC

1.The EPIC plan is used by more than 300,000 New York seniors who are over 65. However, EPIC members only represent 10% of New York’s 3 million seniors and there are many more people who are eligible and could benefit from the program.

2. EPIC is not a substitute for a Medicare Part D drug plan, but rather a supplement for low to moderate income individuals. In many cases, EPIC will actually pay for part or all of your Part D premium.

3. The EPIC program income eligibility is $75,000 for an individual and $100,000 for couples. Income is based on your last year’s federal 1040 tax return, line 22 (total income). EPIC does not look at your assets (cash, investments, property etc) or your expenses, only your reported income and they verify what you report with your tax return.

4. EPIC provides financial assistance in two areas- it provides a subsidy for individuals who’s income and resources are above Medicare’s Low-Income Subsidy (LIS) criteria but below EPIC’s limit of $23k (ind.) and $29k (couple), to pay for the cost of your Part D premium (up to $39/mo. in 2018). Secondly, EPIC subsidizes the cost of of your prescription drugs (after any deductible in the plan has been met). Your cost of medications with the EPIC subsidy will range from only $3 to $20 per monthly prescription.

Medicare DrugCost

This benefit can be worth tens of thousands of dollars for people with expensive medications to treat chronic diseases such as hepatitis B, diabetes, inflammatory diseases, multiple sclerosis and various form of cancers. This includes medications that may be excluded from your Part D’s formulary.

5. EPIC can pay for either part of your Medicare Advantage’s drug component or a stand alone Part D plan that is used with original Medicare and Medigap plans

6. EPIC can even pay for Part D penalties in some cases if your drug plan premium is under $39/month

7. If you are eligible for an EPIC Part D subsidy, don’t quickly sign up for a zero premium Medicare Advantage plan. You should look at better plans with lower co-pays and added benefits- dental, health club that may cost you little or nothing to upgrade your health plan coverage and may not have a deductible.

8. Applying for EPIC is easy- just complete the half page application and mail it in.

9. EPIC has a small annual member fee for low-income people (under $20k (i) and $26k (c) who are eligible to receive the Part D premium subsidy up to $39/mo. For people with income over $20K (i) or $26k (c), there is no program fee but rather a deductible that needs to be met based on your income. The annual deductible starts at $62 (i)  and $182 (c) and increases with your income. The deductible needs to be met before you’re eligible to receive the subsidized prescription rates..

10. EPIC members are entitled to a Special Enrollment Period once a year, if they want to change their prescription drug plan. This could result in better medical and drug coverage or lower premiums.

For more information and an EPIC application call 800-332-3742

Buyer Beware in Selecting a Medicare Prescription Drug Plan (PDP)

med prices

Individuals who use original Medicare A & B for their medical care, with or without a Medigap Plan (not a private Medicare Advantage plan), need to check the formulary and costs of various private insurer PDPs that are available in your area very carefully. And, don’t assume that an insurer that provides a good value for one type of plan (eg. MA or Medigap) provides the same quality, value and coverage in their PDPs. Unlike MA plans that include the same medication formulary, PDPs often have different medications, deductibles and co-pays among their various plans, so check carefully.

An example is United HealthCare, who is a leader in sales and value for their Medigap plans in NYS, ranks much lower in sales & value for their MA and PDPs. There are also dramatic differences in the drug formularies and subscriber cost among the 3 different UnitedHealthCare PDPs that are offered.

The UHC Rx Preferred plan includes over 3,500 drugs on their formulary and has their most expensive premium ($91/mo. but does not include a deductible). By comparison, the RX Savers Plus plan excludes over 400 drugs that are included in the Preferred plan for $55/mo. and includes a $405 deductible. And their lowest cost premium plan is the UHC RX Walgreens plan for $26.50/mo. with a $405 deductible, but it doesn’t cover 500 medications that are included in the high premium cost UHC Preferred plan.

Other popular insurers such as SilverScripts, Humana and Cigna that offer multiple PDPs in NYS also share similar issues which makes it difficult for an individual to clearly understand and choose a plan that includes their medications at a price they can afford. provides a valuable, free Plan Finder service that allows you to anonymously enter your medications and your preferred pharmacies and then compare the total cost of different plans (including MAs and PDPs) from different companies that you are considering.

Once you enter your medications You will also see differences in:

  • Your medications that are not included on the plan formulary.
  • Your medications that have restrictions.
  • Your brand named medications that have generic alternatives.
  • Your cost or a one month or a 3 month supply of medications from different pharmacies.
  • And, finally the total comparative cost differences of each plan including their premiums, deductibles and co-pays that you are considering.


Another nice added feature is that your Plan Finder medication data can be printed and is stored anonymously online. It can be retrieved (with your assigned Drug List ID number and Password date for your future review and updating.

Investing some time in objectively comparing coverage and costs differences of your Medicare plan options can save you money and problems in the future.

If you or your family members needs assistance, you can contact the free State Health Insurance Assistance Program at or 800-Medicare.



Winners and Losers in the Repeal of the Affordable Care Act (aka Obamacare)


With the election of Donald Trump as president, Congressional Republicans are scrambling to come up with a repeal and replace plan that is acceptable to their various factions and president-elect Trump.

House Republicans have a lot of experience in successfully approving bills to repeal the ACA more than 60 times (without a replacement plan) over the past 6 years knowing that the Senate lacked the necessary votes to approve their bill.

While Republicans have labeled the ACA a disaster since it began 6 years ago, they have opposed every opportunity to work with the President and Democrats to design and improve the health insurance legislation. They have also been successful in arm-twisting Republican members of Congress and Republican governors to oppose the establishing state insurance exchanges, expanding Medicaid and providing tax credit subsidies to eligible low-moderate income uninsured Americans. Their actions have had had a negative impact on the large percent of workers who’s employers do not offer health insurance and the 40% of workers who are treated as “contingent” with no employer commitment to a work schedule or any benefits including health insurance.

However, the ACA has succeeded in enrolling more than 20 million people in exchange plans and another 14 million people have enrolled in expanded Medicaid in 31 states. This includes 16 Republican governors.


The Trump Wildcard

Now that Trump has been elected after campaigning on repealing and replacing the ACA, the fun really begins. While many people have jumped on the repeal bandwagon, the vast majority of people opposing the ACA don’t know what the impact will be on their ability to buy health insurance and receive services at a reasonable cost in the future.

The repeal and replacement of the ACA will also affect small businesses, state and local governments, health care providers and facilities, insurance companies & brokers, employees of large businesses and national and regional economies. The great uncertainty that remains is what specifically will be lost and gained.

Trump has campaigned as an independent, populist who is the “peoples’ choice” who is not indebted to any special interests. Time will tell.


Who are the Winners of the ACA Repeal?

Career Republican Politicians

The obvious, big initial winners from the repeal of Obamacare are career Republican politicians who have opposed all forms of tax-supported social supports including Social Security, Medicare, Medicaid and every universal health insurance proposal presented over the past 100+ years, including those proposed by various Republican presidents.

It should be noted that the US spends more than double what every other country spends for health care and prescriptions drugs and has poor health outcomes. Our system is a patchwork of multiple insurers, providers, payers that is costly, inefficient and ineffective that leaves millions uninsured with chronic and costly medical conditions.

From a political standpoint, opponents want to kill, not improve or replace, “Obamacare”. They want to obliterate President Obama’s landmark legislation from the history books.

Higher Income Individuals and Business Owners

Other winners are higher income individuals, who have experienced an increase taxes as a result of the ACA and employers who have experienced increased costs associated with compliance and implementation of the ACA. What is unknown is the cost of repercussions resulting from the repeal of the ACA.

Insurance Companies

Large, national for-profit insurers have to make the most changes to comply with and participate in selling uniform ACA insurance policies in both state and the federal insurance exchanges. Some insurers chose not to participate, others entered the exchange market late after millions were already enrolled and others, such as Aetna, United Healthcare and Humana dropped out of exchanges for 2017 as federal subsidies for catastrophic claims were expiring and their plans for merging with smaller companies were being scrutinized by federal regulators.

With potentially millions of insurance subscribers displaced as a result of the ACA repeal, it will likely cause a “death spiral”, state and federal insurance exchanges and plans for individuals who are not covered by group insurance plans. If it does, insurers will be losers of both subscribers and income. If insurers can negotiate positive changes for them with rate-setting, regulations and federal subsidies for high-need subscribers and regulator support for planned insurer mergers, they will be big winners.

Who are the Losers with the ACA Repeal?

  • The majority of Americans who have indicated in polls, that they only want improvements, not repeal, of the ACA.
  • Individuals who have pre-existing conditions may return to paying between $15,000 (ind.) and $30,000 (fam.) a year for private policies with increased co-pays and deductibles.
  • 14 million low-income individuals may lose their expanded Medicaid eligibility in 31 states
  • Young adults may find their new health insurance costs are unaffordable and chose to go uninsured.
  • Individuals with pre-existing conditions, chronic diseases and those that require costly medical & surgical treatment may find insurance & health care unaffordable and file for a medical bankruptcy.
  • Families with young-adult children, less than 26 years old, who have been covered on their employers’ family plans, may have significant new costs.
  • People who are at risk of serious diseases that may not be able to afford preventative screening tests that have been free.
  • Employees and employers who will require more education and support to understand differences in new  regulations, plans, coverage, benefits and true costs. This will have a negative effect on employee morale and productivity.
  • Insurance companies will lose up to $20 million existing ACA insurance plan subscribers along with up to $16 million in subsidies for low-middle income individuals.
  • Loss of federal tax revenue from select taxes and closed loopholes included in ACA to pay a portion of insurance costs.
  • Loss of brand-name prescription drug discounts and higher out-of-pocket expenses. for seniors.
  • Small employers, who have purchased or directed low-moderate income employees to insurance exchanges for subsidized policies, may face higher health insurance expenses and/or higher employee turnover.
  • Hospitals and health care professionals will likely face loss of insurance income, an increase in bad debts and increased administrative expenses to manage changes.
  • Health care quality and cost containment standards and strategies will be lost.
  • Loss of consumer protections and assistance in navigating a very complex and costly insurance/healthcare system


CBO Report on the Impact on Repealing the ACA

The non-partisan Congressional Budget Office (CBO) and the staff of the Joint Committee on Taxation (JCT) just released a report on the impact of repealing the ACA on insurance coverage and premiums.

Without any replacement plan in place, the impact will be devastating including:

  • Increasing the number of uninsured by 18 million in the first year and rising to 32 million by 2026.
  • Premiums for individual policies would increase by 20%-25% in the first year and increasing by 100% by 2026
  • Eliminating subsidies to insurers and the individual mandate will destabilize the insurance market and reduce the participation of insurers in selling policies.
  • In the first year after subsidies are repealed, about 50% of the nation’s population lives in areas that would have no access to insurers participating in the individual policy market.

Final Thoughts

The first 100 days of the Trump administration should be very interesting. There will be a major transformation of The White House and management personnel.

And, the repeal and replacement of the ACA is just one of many domestic and foreign promises that Trump has made, but will be implemented by people who have largely not had any similar responsibilities or experience.

The public expects the positive results that Trump has promised and we will soon see the public’s reaction to the new administration’s performance.

With Congressional midterm elections scheduled for 2018, Republicans, who are up for re-election, have their political survival at stake.