This is the eighth post in an ongoing series regarding changes in health care that may take place—and actual changes that do take place—with the Trump administration. The likely implementation issues to be encountered for both potential and actual changes are described, based on detailed methods of analysis. The emphasis is on what these shifts mean for legal practices and how attorneys may prepare in the most effective ways.

The American Health Care Act (AHCA) was introduced in the House of Representatives (as HR 1628) on March 6, 2017 and withdrawn on March 24. This bill was an initial step in a strategy for repeal and replacement of the Affordable Care Act (ACA)—also known as Obamacare.

The proposals presented in the AHCA are still the subject of intense debate and future directions of change remain unclear. While this discussion is taking place, it is important to note that the AHCA would have implemented major funding cuts for older adults.

The AHCA included a shift from the subsidies provided by the ACA, through the Exchanges, to tax credits to be provided to individuals, as a way to help individuals pay for private insurance. Expanded Medicaid was to be phased out, while classical (pre-ACA) Medicaid was to be converted to state grants with payments to be based on capitation or fixed block grants for the various categories of enrollees. The individual and employer mandates were to be eliminated.

The AHCA would strongly affect access to health care for older adults in three major ways: (1) as proposed, the tax credit values would sharply reduce financial assistance for middle-income seniors (ages 50 to 64) who had previously qualified for Exchange subsidies; (2) the phasing out of expanded Medicaid would reduce financial support for lower-income single adults who had gained Medicaid coverage; and (3) the conversion of classical Medicaid to state grants would pressure assistance for the aged, blind and disabled enrollees, including those in need of long-term care assistance.

A large part of the total savings to be achieved by the AHCA would have come from these reductions in public payments for care. This would particularly affect older adults with midlevel incomes, who would have to pay much more for private insurance; low-income seniors in this age group who had gained coverage through expanded Medicaid; and seniors needing long-term care (LTC) through Medicaid.

In a letter to 50 state governors, the Department of Health and Human Services (HHS) encouraged Medicaid programs to create a renewed emphasis on the services being provided to disabled populations, observing that the higher state reimbursement rate for expanded Medicaid coverage for adults “provided states with an incentive to deprioritize the most vulnerable populations.” The letter encouraged Medicaid programs to ask for various waivers and demonstration projects as one approach to change.

These combined actions proposed reductions in financial support to pay for health care services for seniors, as well as similar reductions in support for the elderly and disabled. The states were invited to explore changes in care arrangements for these groups.

Based on various statements of intent, it seems that the AHCA was expected to force reductions in the costs of care by capping funding, thereby forcing the health care system to adapt. There seems to have been a belief that if resources were restricted, then service providers, state agencies and insurance companies would come up with care solutions to fit the available funds. This was an optimistic perspective that might have held up under testing. In any case, a transition period between the present and such future care arrangements would be tumultuous. These proposals suggested that older adults and disabled individuals (and their families) were likely to have strong negative reactions to the AHCA.

If this bill is reintroduced in the House, it is reasonable to expect that major attacks will be mounted by groups of individuals and various organizations that would be significantly affected by its possible passage. It is not clear that advocates for the AHCA are prepared to experience and deal with such negative reactions.


This post was written by Ferd H. Mitchell and Cheryl C. Mitchell, Thomson Reuters authors and attorney partners at Mitchell Law Office in Spokane, Wash. They are active in elder law and health law practice areas and have been working together on programs and activities on behalf of the elderly and in health care for more than 25 years. During their studies, they have visited and evaluated the health care systems of Japan and several countries in Europe to learn how the needs of the elderly are assessed and met in other countries, and they have been better able to understand the U.S. health care system and related care issues from these visits. More about the lessons learned from the ACA and issues involved in health program changes may be found in the 2017 edition of the authors’ book, Legal Practice Implications of Changes in the Affordable Care Act, Medicare and Medicaid, published by Thomson Reuters. More about these methods of analysis may be found in Mitchell & Mitchell, Adaptive Administration, published by Taylor and Francis. Follow the links below to read previous installments from this series:

Part One

Part Two

Part Three

Part Four

Part Five

Part Six

Part Seven

The views and opinions expressed in this post are those of its authors alone.