By JULIE ROVNER
Kaiser Health News

Six years into building its business around the Affordable Care Act, the nation’s $3 trillion health care industry may be losing that political playbook.

Industry leaders, like many voters, were stunned by the election of Donald Trump and unprepared for Republicans’ plans to “repeal and replace” Obamacare.

In addition, Trump’s vague and sometimes conflicting statements on health policy have left industry officials guessing as to the details of any substitute for the federal health law.

“It will be repealed and replaced,” Trump said Sunday in an interview on CBS’ “60 Minutes.” At the same time, he vowed to preserve popular provisions of the law like ensuring that people with pre-existing conditions can get insurance and allowing young adults to stay on their parents’ health plans.

Charles (Chip) Kahn, chief executive of the Federation of American Hospitals, said that before the election, health groups had not been meeting with Republicans about a rewrite of the law “because the working assumption was we had a program that wasn’t going anywhere. That working assumption is now no longer operative.”

Upending the health law plays havoc with a health industry that had invested heavily in strategies geared to the ACA’s financial incentives. The flipped script initially left some industry groups speechless. Others issued bland statements pledging cooperation with the next administration as they awaited greater clarity from the next president.

Said Donald Crane, who heads CAPG, a national trade group for physician organizations: “Nobody was ready for this. We didn’t have a Plan B.”

Reason to worry
The results appear to have rattled the fragile industry coalition that the Obama administration carefully crafted to support the law. Looking ahead, some health sectors might have even more reason to worry.

The hospital industry may be the most vulnerable to proposed changes, which could result in millions of Americans losing health coverage, both through the insurance exchanges and expansion in the Medicaid program for those with lower incomes.

Hospitals cut a deal with Congress and the Obama administration in 2009, when the Affordable Care Act was being drafted. They agreed to substantial cuts in Medicare and Medicaid reimbursement, anticipating that those cuts would be offset by increases in paying customers who were newly insured.

“If you’re a hospital, you’ve sort of made this deal that you’re going to get more coverage [so you] accepted Medicare cuts,” said Dean Rosen, a longtime Republican congressional staffer who now represents hospital, insurance and other health interests in Washington. “What’s going to happen now?”

If expanded coverage under Obamacare goes away, Kahn said, then those cuts should be restored, “because those were done with the notion that uninsured people were going to have coverage.”

Other sectors of the industry appear either at somewhat less risk or could even come out ahead under Trump and a Republican Congress.

While the pharmaceutical industry would stand to lose paying customers if the law was changed in a way that people lose insurance coverage, it could actually be a winner under a Republican president and Congress. That’s because the industry will be less at risk of the price controls that Democrats were vowing to try to impose. Trump mentioned drug prices a few times on the campaign trail, but references to drug pricing are not on the health agenda outlined on the transition website.

Insurers express mixed feelings about a potential repeal. The government-run online marketplaces where consumers can purchase federally subsidized coverage are a key pillar of Obamacare. But many insurers have complained about losing money in those marketplaces because too many sick people are signing up and healthier consumers are sitting out.

Some industry executives predict that the marketplaces will be curtailed and Republicans will try to shift some of that coverage to state Medicaid programs. One of the biggest growth opportunities for insurers under Obamacare has been the expansion of Medicaid managed-care contracts under which private firms take responsibility for a large group of low-income enrollees for a fixed amount of money.

That privatization of Medicaid could accelerate under the Trump administration, some experts predict.

“Whether it’s Medicaid managed care or the private insurance model, these companies get their money either way,” said Paul Ginsburg, a health economist and professor at the University of Southern California. “I don’t see much of a threat to insurers.”

The picture is even rosier considering the insurance industry dodged a debate about a government-run public option, backed by Democratic presidential nominee Hillary Clinton, that would have competed directly against private health plans.

‘Starting from zero’
The proposed changes extend beyond the health law. Many insurers expect Republicans to champion an expansion of privately run Medicare Advantage plans. These alternative plans often offer additional health benefits not covered by traditional Medicare, but they were targeted in the health law for cutbacks because back then they were more expensive to the government than traditional Medicare.

“Medicare Advantage is poised to be the big winner consistent with Republican support of privatizing Medicare,” said Ana Gupte, a health care analyst at Leerink Research.

Nothing on health care is bound to change right away. Republicans have promised to put their early focus on the health law, but even with a quick vote on repealing major parts of it, they are expected to set a lengthy transition period that keeps the current framework in place while a replacement plan is developed. At that point, Republicans will encounter many of the tough choices Democrats struggled with while writing the landmark 2010 health law. They spent more than two years trying to craft intricate compromises among industry leaders.

“The Republicans will face the same issues as the architects of the Affordable Care Act,” Crane said. “How do we fund it? Whose scalp do you take? And how do you get the most people covered for the lowest cost at the highest quality?”

Jeff Goldsmith, a health industry consultant in Charlottesville, Va., said the Republicans are “starting from zero in dealing with this. They have no idea about the subtleties.”

Some industry leaders are encouraged that Trump has softened his talk of “repeal and replace” and seems open to keeping at least some of the provisions of the health law.

Bernard Tyson, CEO of Kaiser Permanente, a large health system and insurer based in Oakland, Calif., took some comfort from Trump’s own words.

He “said no one in this country should suffer unnecessarily because they can’t afford health care. That tells me we have room to work here,” Tyson said. “I believe when they get under the hood of the Affordable Care Act, I think we may start to see and hear different conversations.”

Ginsburg predicts that Trump might apply his marketing skills to health reform.

“If you really want to continue with 20 million people having coverage,” Ginsburg said, “it will kind of look like the Affordable Care Act. There will be rebranding, but a lot of the elements will remain.”

Kaiser Health News (KHN) is a nonprofit news organization committed to in-depth coverage of health care policy and politics. The Washington, D.C.-based news service is a partner of KHI News Service.

WICHITA, Kan. (AP) — The convictions of two men who relied on a Kansas law to protect them from prosecution for federal firearms violations have raised questions about the legal basis for gun control.

The National Firearms Act is a part of the Internal Revenue code enacted under Congress’ power to levy taxes. The prosecution of Shane Cox and Jeremy Kettler raises the question of whether that taxing authority can be used to regulate firearms that stay within state borders.

A jury found them guilty of federal firearms violations in a case with Second Amendment and state rights implications that even the judge overseeing it expects to ultimately end up before the U.S. Supreme Court.

Their defense attorneys contend their clients believed the Kansas law made their activities legal.

WICHITA, Kan. (AP) — A probable cause affidavit says a Wichita man was tortured before he was killed over the loss of $185 in a methamphetamine deal.

The document obtained Monday from the court by the Associated Press details the sexual torture of both 33-year-old Scottie W. Goodpaster Jr. and a woman who survived.

Four people have been charged with kidnapping, murder and other charges, and a fifth person was charged with kidnapping and robbing the female victim.

The woman told police she was made to watch Goodpaster’s ordeal on Nov. 5. The body of the missing man was found about a week later in rural Harvey County.

A staple gun was used to put staples into his eyes and mouth, and a knife was used to cut his ear and genitals.

By FRANK BAJAK
Associated Press

LOS EBANOS, Texas — Forget Donald Trump’s Great Wall.

The people who live in the bustling, fertile Rio Grande Valley, where the U.S. border meets the Gulf of Mexico, think a “virtual wall” of surveillance technology makes a lot more sense. It’s already in wide use and expanding.

Erecting a 40-foot concrete barrier across the entire 1,954-mile frontier with Mexico, as Trump promised during the presidential campaign, collides head-on with multiple realities: geology, fierce local resistance and the question of who pays the bill.

People cackled at Trump’s idea that Mexico would willingly deliver the billions required. Mexican officials say they won’t. So few locals were surprised when the president-elect seemed to soften his position five days after the election, saying the wall could include some fencing.

“The wall is not going to stop anyone,” Jorge Garcia said.

Garcia expected to lose access to most of his 30-acre riverside ranch after the U.S. Border Fence Act was enacted a decade ago under President George W. Bush. Garcia is still waiting to see if the Border Patrol will put a fence or wall on the sliver of land it surveyed and promised to pay $8,300 for.

Under the law, 652 miles of border barrier were built, mostly in Arizona. The 110 miles of fences and fortified levees that went up in Texas are broken lines, some as much as a mile and a half from the river.

The Garcias believe they and the rest of Los Ebanos’ villagers were spared because the erosion-prone clay soil is simply too unstable.

Geology conspires against wall-building up and down the Rio Grande Valley. Its accomplices are a boundary water treaty with Mexico and endangered-species laws. Catwalks and tunnels had to be built into border barriers to accommodate ocelots and jaguarundi, two species of wild cat.

The plentiful breaks in the border barrier, meanwhile, include an entire flank of the River Bend golf club and resort in Brownsville — “gaps of privilege” for the well-connected, according to one critic.

Other landowners fought the Border Patrol in court.

“The wall might make mid-America feel safer, but for those of us that live on the border, it’s not making us feel any safer when we know that people can go over it, around it, under it and through it,” said Monica Weisberg-Stewart, security expert for the Texas Border Coalition, a consortium of regional leaders.

A poll conducted in Southwest border cities in May found 72 percent of residents opposed to a wall. The Cronkite News-Univision-Dallas Morning News poll had a 2.6 percent error margin.

Local politicians have found inventive ways to make wall-building palatable. A 20-mile stretch in Hidalgo County consisted of a fortified levee topped with a fence. In 2010, that levee held back flooding. The cost was about $10 million a mile, though.

In the Nov. 8 election, only three Texas border counties — all sparsely populated — went for Trump. The rest are solidly Democratic and back President Obama’s more lenient immigration policies.

The U.S. side of the border is quite safe, Weisberg-Stewart said. “We are not in a war zone.”

In fact, cross-border trade has been booming. In 2014, more than $246 billion worth of goods and 3.7 million trucks crossed the Texas-Mexico border, according to the coalition.

While much of the border’s Mexican side has been afflicted by drug cartel-related violence, crime in the Rio Grande Valley, home to 1.3 million people, has been consistently lower than other Texas cities.

The Border Patrol’s buildup after 9-11 is one reason, argues a former chief, David Aguilar. Since 2004, the year he was named to the job, the number of agents on the southwest border has climbed from 9,500 to more than 17,500.

Meanwhile, the number of border apprehensions is down from a peak of 1.6 million in 2000 to 409,000 in the year ending in September. Nearly half were caught in the Rio Grande Valley.

The Great Recession that began in 2008 made the U.S. less attractive to Mexican migrants, and Central Americans fleeing violence and poverty in their homelands now account for more than half the arrivals.

Many migrants In the Rio Grande Valley turn themselves in at border bridges. After processing, released migrants are given court dates in destination cities where relatives typically await. Others are sent to detention centers for further interviews about their asylum claims.

The Border Patrol nevertheless credits surveillance technology for curbing illegal entries, including tower-mounted surveillance cameras, motion sensors and laser pointers.

Since 2013, the agency has also had five blimp-like aerostats that float from 1,000 to 5,000 feet above the valley on tethers and are equipped with remote-controlled cameras. High-flying Predator drones are additional eyes in the sky, patrolling vast areas of southwest borderlands since 2011.

At a community center in McAllen, Texas, a 21-year-old Guatemalan who is eight months’ pregnant was bound for Kansas after turning herself in. Ingrid Guerra said she was fleeing an abusive relationship. The father of her other child, a 2-year-old who stayed behind with Guerra’s mother, was killed in a drunken brawl, she said.

“Back there,” Guerra said of Guatemala, “they kill at the drop of a hat.”