Health care reform will be a top-priority issue for the incoming Congress and President-elect Donald Trump. Allowing insurance companies to sell policies across state lines has become a central element of Republican promises to replace “Obamacare” with something better. But that idea didn’t make Iowa Insurance Commissioner Nick Gerhart’s list of ten ways to improve the Affordable Care Act.

On the contrary, Gerhart wrote, selling health insurance policies across state lines would not be “a major factor that would help drive down costs.”

He also warned members of Congress against repealing the 2010 health care reform law without simultaneously passing its replacement.

Gerhart hopes Trump will extend for another two years the “transitional (grand-mothered) plans” that don’t conform to all ACA standards but are an economical choice for many consumers. He has lots of ideas for improving the Affordable Care Act.

But Iowa’s Republican insurance commissioner warned, “there are no easy fixes” for the the health care reform law. Here’s his take on a major GOP talking point:

Much is written about selling insurance across state lines. I do not see that as a major factor that would help drive down costs. Those insurers that would sell across state lines would have to comply with applicable state mandates, and would still have to build a network of doctors for competitive pricing. New companies can enter states today with ease and many companies sell in multiple states. The issue is the cost to contract with doctors in those states. More competition in insurance sounds good, but if those carriers cannot get enough scale to get competitive pricing arrangements with providers they will be priced out of the market.

The chief executive of Blue Shield of California identified another problem with the cornerstone of GOP promises to replace Obamacare:

“It will push health plans to find the regulatory body or state with the fewest number of regulations,” [Paul] Markovich said. “It’s a race to the lowest common denominator and least rich benefits. That is what we want to avoid, and I don’t think it will do much to increase competition. I find it perplexing.”

Tony Leys brought Gerhart’s post to my attention in his story for Des Moines Register.

“If the new Congress passes a bill to repeal all of the ACA, I hope that a replacement for the ACA is stapled to that bill,” Gerhart wrote in an essay he posted online. “An immediate repeal would lead to devastating consequences in the disruption of people’s care, and create even more uncertainty for millions of Americans. To ease the uncertainty, a transition time is required for any whole or partial suggested change.”

Republican Donald Trump, who won last week’s presidential election, vowed during the campaign to immediately repeal the law. He appeared to soften that stance after the election, saying he would like to keep parts of Obamacare, such as a ban on insurers denying coverage due to applicants’ pre-existing health problems.

Gerhart agrees with many Obamacare critics who want to jettison the law’s controversial requirement that most Americans have insurance. Proponents of the mandate say it’s needed to keep people from waiting to purchase coverage until they’re seriously ill. Gerhart wrote that Congress could accomplish the same thing by only allowing people to buy health insurance every three years. He would only allow exemptions to that rule if applicants had a specific, documented reason, such as losing coverage due to a job loss. […]

In an interview Wednesday, Gerhart said a sudden repeal of the entire law would cause companies to abandon the health-insurance market. “I think carriers are starved for predictability and stability,” he said. He hopes national leaders can work together to come up with a workable alternative. “You can call it repeal. You can call it replace. You can call it reform,” he said.

Margot Sanger-Katz explained here why it’s not economically feasible to protect people who have a pre-existing condition in the absence of a mandate to purchase health insurance.

Before Obamacare, several states tried policies like this, and required insurance companies to sell insurance to everyone at the same price, regardless of health histories. The results were nearly the same everywhere: Prices went way up; enrollment went way down; and insurance companies fled the markets.

Some states hobbled along with small, expensive markets. Some experienced total market collapse and repealed the policies. Prices in those markets typically became so high that they were really a good deal only for people who knew they’d use a lot of health care services. And the sicker the insurance pool got, the more the companies would charge for their health plans. […]

New York is a great case study. Before Obamacare, it had the pre-existing conditions policy, but without subsidies or a mandate. When the Obamacare rules kicked in, premiums there went down by 50 percent. […]

It won’t be easy to keep the basic architecture of Obamacare while plucking out its least popular pieces. (Another provision that Mr. Trump says he likes, the requirement that insurers cover young adults on their parents’ policies, would be easier to save.)

The GOP-led Congress passed dozens of Obamacare repeal bills in recent years, but never with any replacement plan attached. They’re about to find out governing is much harder than grandstanding.

Any relevant comments are welcome in this thread. How long do you think it will take for a health care reform bill to reach Trump’s desk?

P.S.-Before Trump’s people take over the U.S. Department of Health and Human Services and send this information down the memory hole, here’s a federal government fact sheet on the impact of Obamacare for Iowans.

5 Years Later: How the Affordable Care Act is Working for Iowa

The Affordable Care Act is working to make health care more affordable, accessible, and high quality for the people of Iowa.

Better Options

Making health care more affordable and accessible through the Health Insurance Marketplaces: Through the Marketplace, Iowans had the option of signing up for quality health coverage at a price they could afford. Whether they visited the simpler, faster and more intuitive website at HealthCare.gov or contacted the call center, they found more choices and competitive prices.

In Iowa, 45,162 consumers selected or were automatically re-enrolled in quality, affordable health insurance coverage through the Marketplace as of Feb. 22. Nationwide, nearly 11.7 million consumers selected a plan or were automatically enrolled in Marketplace coverage.

Marketplace Signups and Tax Credits in Iowa:

85 percent of Iowa consumers who were signed up qualified for an average tax credit of $260 per month through the Marketplace.
56 percent of Iowa Marketplace enrollees obtained coverage for $100 or less after any applicable tax credits in 2015, and 85 percent had the option of doing so.
Iowa consumers could choose from an average of 23 health plans in their county for 2015 coverage.
13,963 consumers in Iowa under the age of 35 are signed up for Marketplace coverage (31 percent of plan selections in the state). And 11,711 consumers 18 to 34 years of age (26 percent of all plan selections) are signed up for Marketplace coverage.
Iowa has received $59,683,889 in grants for research, planning, information technology development, and implementation of its Marketplace.

Open enrollment for 2015 coverage ended on Feb. 15, 2015. Open enrollment for 2016 coverage runs from November 1, 2015 to January 31, 2016. Consumers should visit HealthCare.gov to see if they qualify for a Special Enrollment Period because of a life change like marriage, having a baby or losing other coverage. Enrollment in Medicaid and the Children’s Health Insurance Program is open year round.

Reducing the number of uninsured Americans: Nationwide, since the Affordable Care Act’s coverage expansion began, about 16.4 million uninsured people have gained health insurance coverage – the largest reduction in the uninsured in four decades. And Gallup recently announced that the uninsured rate in Iowa in 2014 was 8.3 percent, down from 9.7 percent in 2013.

New coverage options for young adults: Under the health care law, if your plan covers children, you can now add or keep your children on your health insurance policy until they turn 26 years old. Thanks to this provision, over 2.3 million young people who would otherwise have been uninsured have gained coverage nationwide.

Expanding Medicaid: Thanks to the Affordable Care Act, states have new opportunities to expand Medicaid coverage to individuals with family incomes at or below 133 percent of the federal poverty level (generally $32,253 for a family of four in 2015). This expansion includes non-elderly adults without dependent children, who have not previously been eligible for Medicaid in most states.

Thirty states plus DC have expanded Medicaid under the Affordable Care Act, including Iowa. And as of January 2015, 19,018 Iowans have gained Medicaid or CHIP coverage since the beginning of the Health Insurance Marketplace first open enrollment period. Across the nation, approximately 11.2 million more Americans are now enrolled in Medicaid and CHIP.

Better Value

Providing better value for your premium dollar through the 80/20 Rule: Health insurance companies now have to spend at least 80 cents of your premium dollar on health care or improvements to care, rather than administrative costs like salaries or marketing, or they have to provide you a refund. This means that 14,598 Iowans with private insurance coverage benefited from $1,753,306 in refunds from insurance companies, for an average refund of $206 per family because of the Affordable Care Act.

Scrutinizing unreasonable premium increases: In every State and for the first time under Federal law, insurance companies are required to publicly justify their actions if they want to raise rates by 10 percent or more. Since implementing the law, the fraction of requests for insurance premium increases of 10 percent or more has dropped dramatically, from 75 percent to 14 percent nationally. To date, the rate review program has helped save Americans an estimated $1 billion.

Removing lifetime limits on health benefits: The law bans insurance companies from imposing lifetime dollar limits on health benefits – freeing cancer patients and individuals suffering from other chronic diseases from having to worry about going without treatment because of their lifetime limits. Already, 1,187,000 people in Iowa, including 433,000 women and 311,000 children, are free from worrying about lifetime limits on coverage. The law also restricts the use of annual limits and bans them completely starting in 2014.

Ending discrimination for pre-existing conditions: As many as 1,290,303 non-elderly Iowans have some type of pre-existing health condition, including 167,995 children. Today, health insurers can no longer deny coverage to anyone because of a pre-existing condition, like asthma or diabetes, under the health care law. And they can no longer charge women more because of their gender.

Expanding mental health and substance use disorder benefits: The Affordable Care Act increases also access to comprehensive coverage by requiring most health plans to cover ten essential health benefit categories, to include hospitalization, prescription drugs, maternity and newborn care, and mental health and substance use disorder services. The health care law expands mental health and substance use disorder benefits and federal parity protections for 62 million Americans nationwide, including 665,355 Iowans.

Better Health

Covering preventive services with no deductible or co-pay: The health care law requires many insurance plans to provide coverage without cost sharing to enrollees for a variety of preventive health services, such as colonoscopy screening for colon cancer, Pap smears and mammograms for women, well-child visits, and flu shots for all children and adults.

Because of the Affordable Care Act, 76 million Americans with private health insurance gained preventive service coverage with no cost-sharing, including 813,000 in Iowa. And women can now get coverage without cost-sharing of even more preventive services they need. Of the 76 million Americans with expanded access to free preventive services, 29.7 million are women, including 305,000 in Iowa receiving expanded preventive services without cost-sharing.

Investing in the primary care workforce: As a result of historic investments through the health care law and the Recovery Act, the numbers of clinicians in the National Health Service Corps are near all-time highs with 9,200 Corps clinicians providing care to approximately 9.7 million people who live in rural, urban, and frontier communities. The National Health Service Corps repays educational loans and provides scholarships to primary care physicians, dentists, nurse practitioners, physician assistants, behavioral health providers, and other primary care providers who practice in areas of the country that have too few health care professionals to serve the people who live there. As of September 30, 2014, there were 88 Corps clinicians providing primary care services in Iowa, compared to 38 in 2008.

Increasing support for community health centers: The Affordable Care Act increases the funding available to community health centers nationwide. Health Center grantees in Iowa have received $75,140,569 under the health care law to offer a broader array of primary care services, extend their hours of operations, hire more providers, and renovate or build new clinical spaces.

Of the $75,140,569 awarded to Iowa, $2,242,742 was awarded to Iowa health centers to help enroll uninsured Americans in the Health Insurance Marketplace. Overall, since 2013, Iowa health centers used these funds to help more than 62,183 Iowa residents with enrollment into affordable health insurance coverage, with 11,770 of those being assisted between October and December 2014. These investments ensure that health centers continue to be a trusted resource for assistance with enrollment in the Marketplace, Medicaid and CHIP in Iowa.

In Iowa, 14 health centers operate 65 sites, providing preventive and primary health care services to 179,599 Iowans, including 39,439 Latinos and 22,886 African Americans.

Preventing illness and promoting health: Through Fiscal Year 2013, Iowa has received $36,959,624 in grants from the Prevention and Public Health Fund created by the health care law. This fund was created to support effective policies in Iowa and nationwide, such as initiatives focused on tobacco cessation, obesity prevention, health coverage enrollment assistance, and increasing the primary care and public health workforce, so that all Americans can lead longer, more productive lives.

A Stronger Medicare Program

Making prescription drugs affordable for seniors: In Iowa, people with Medicare have saved nearly $154,777,526 on prescription drugs because of the Affordable Care Act. In 2014 alone, 54,336 individuals in Iowa saved over $46,293,097, or an average of $852 per beneficiary. In 2015, people with Medicare in the “donut hole” received a 55 percent discount on covered brand name drugs and a 35 percent discount on generic drugs. And thanks to the health care law, coverage for both brand name and generic drugs will continue to increase over time until the coverage gap is closed. Nationally, over 9.4 million people with Medicare have saved over $15 billion on prescription drugs since the law’s enactment, for an average savings of $1,598 per beneficiary.

Covering preventive services with no deductible or co-pay : With no deductibles or co-pays, cost is no longer a barrier for seniors and people with disabilities who want to stay healthy by detecting and treating health problems early. In 2014 alone, an estimated 39 million people benefited from Medicare’s coverage of preventive services with no cost-sharing. In Iowa, 420,269 individuals with Medicare used one or more free preventive service in 2014.

Cracking down on fraud and abuse: The health care law helps stop fraud with tougher screening procedures, stronger penalties, and new technology. More than $27.8 billion has been returned to the Medicare Trust Funds since 1997 because of these fraud enforcement efforts. For every dollar spent on health care-related fraud and abuse activities in the last three years the administration has recovered $7.70.