Holly Fletcher

hfletcher@tennessean.com

Donald Trump's victory thrust the nation's health care system into uncertainty Wednesday, as the president-elect — backed by a GOP-controlled Congress — sets his sights on dismantling President Obama's Affordable Care Act.

In the days leading up to the election, Trump doubled down on his support for a special congressional session to repeal and replace the ACA, commonly known as Obamacare. It's estimated that a repeal, if implemented in 2018 could cause about 20 million to lose coverage, according to analysis by RAND and The Commonwealth Fund.

That would put additional pressure on the hospital operators based around Nashville — including industry giants Community Health Systems, HCA and LifePoint Health, which were direct beneficiaries of the federal health policy, particularly in states that expanded Medicaid.

The direction of health reform under Trump — and a Republican House and Senate — will be to "greatly diminish (though not abolish), and thus partially unwind an entrenched Affordable Care Act", said former Sen. Bill Frist, R-Tenn., in comments to The Tennessean.

Trump is expected to eliminate the individual and employer mandates as well as greatly reform the underpinnings of the individual market such as healthcare.gov, the minimum coverage requirements and the tax credits that offset monthly premiums for many.

"The effect will be to dismantle the ACA program as we know it today. President Trump will rely almost entirely on the blueprint health plan of (House) Speaker Paul Ryan to provide refundable tax credits to address a consequent likely substantial fall off in the 20 million previously uninsured people who gained insurance under the ACA who will lose it if these policies are implemented," said Frist.

The hospital industry is resilient and has weathered periods of uncertainty in the past, notes Frank Morgan, an equity analyst at RBC Capital Markets, who said he is confident that the Nashville-area companies are equipped to navigate the coming changes.

Still, the companies, along with their peers and other types of health care providers, have described the presidential election as a source of uncertainty in financial filings over the course of the year.

Further complicating executive teams’ abilities to forge their strategies is an absence of details regarding Trump's vision for "replacing" the ACA, industry experts said.

Stocks of health care services companies — often known as hospital operators — tumbled in the wake of the election results as investors began to digest and review what policy reforms mean for the companies.

HCA closed at $72.16, down more than 10 percent from the day before. CHS and LifePoint were at $4.66 and $52.80, down 21.55 percent and 13.51 percent from close on Nov. 8, respectively.

“Here in our town of Nashville, we’re having a tough day,” said Morgan.

Publicly traded insurers remained in the green, however, following losses they’ve sustained on many of the public exchanges.

Critics argue that Trump's expected reforms would put less healthy people at a disadvantage when buying coverage. Prior to the ACA, people with preexisting conditions could be denied coverage.

Beyond Trump's staunch opposition to the ACA, many health care experts are unclear about his other ideas for the sector. A bipartisan panel on health care policy under the next president, convened in Nashville in September agreed that Trump's position on health care was less clear than Democratic nominee Hillary Clinton.

He has favored allowing insurers to sell plans across state lines as well as block grants for states to use for Medicaid programs.

“We see Trump as pretty much an empty suit on healthcare and pharma policies having not given much thought to them and these issues really never broke into his top tier of thematic concerns as was the case with trade, immigration, and foreign policy," Ethan Siegal, founder of the Washington Exchange, told UBS equity analyst A.J. Rice in early November.

House Speaker Paul Ryan, R-Wis., reiterated his commitment Wednesday to scrapping the ACA, contending that it was "collapsing under its own weight."

“As a leading provider for nearly 50 years, we have a long history of working with America's leaders in Washington and across the nation to ensure access to quality healthcare for as many people as possible, and we will continue to do that. The ACA provided coverage for an additional 15 million people, and we will work with President-elect Trump and Congress to maintain access to care for them,” said HCA spokesman Ed Fishbough in a statement to The Tennessean.

Tennessee was a flashpoint this summer in the long-running, partisan ACA debate. Insurers asked for average premium increases ranging from more than 40 percent to more than 60 percent. The state’s insurance commissioner said the exchange was on the verge of collapse because competition and access to policies were at stake.

People are encouraged to continue to enroll in health insurance plans on healthcare.gov. Given that inauguration will be near the end of the enrollment period, experts project changes to the exchanges would take place in 2018.

"The Tennessee Department of Commerce and Insurance will continue to serve as a resource to the new president and members of Congress by discussing our experience, offering insight, and providing a state regulator perspective on health insurance matters," said Julie Mix McPeak, commissioner. "We continue to work with the local carrier community and interested parties to help provide as many insurance options as possible to as many Tennesseans as possible."

Reach Holly Fletcher at 615-259-8287 or on Twitter @hollyfletcher.

Election Night 2016