While President Donald Trump on Friday fulfilled a promise he made to voters to set in motion the repeal of the Affordable Care Act, experts says the real effects won't be seen until his cabinet is in place.
The day of his inauguration Trump signed an executive order that instructs his cabinet to waive fees, taxes or penalties on patients, providers and insurers when it is within their authority to do so.
The executive order puts no policy in place, said Eric Cragun, senior director of Health Policy at Advisory Board. Eliminating penalties requires administrative action from agencies.
[Also: Professor: Trump's executive order on healthcare has limited reach]
That won't happen until after Rep. Tom Price, R-Georgia, is confirmed to lead the U.S. Department of Health and Human Services, Cragun said. The Senate Finance Committee votes Tuesday on whether to confirm Price.
Seema Verma, the proposed administrator the Centers of Medicare and Medicaid Services, will go through a similar process.
"The order that Trumped signed on Friday at this point largely a symbolic step that keeps his campaign process of repeal on day one of his presidency," Cragun said. "We likely won't see any changes, any direct impact on insurers and providers until we have new agency heads in place. That's when we expect they'll follow the executive order."
The executive order empowers agency heads to use their discretion to give waivers, he said.
"It's not like someone flipped a switch," said Michael Abrams, co-founder, vice president and managing partner of Numerof and Associates. "I look at this and think no one should be surprised that Trump is setting forth the framework after all the campaigning, all he said about the ACA."
Abrams also said the order is more of a statement of principles than action. Trump is taking back the power of decision-making from the administration and giving it back to Congress, he said.
"It sets the tone for what happens next," he said.
But while the order could give the cabinet heads authority to waive fees, insurers could challenge in court orders do away with the individual and employer mandate, Cragun said. That's one of many uncertainties concerning Trump, insurers and the ACA.
"Insurers are concerned about uncertainty around the ACA," Cragun said. "They were already concerned. The executive order itself is much more of an incremental step towards uncertainty."
Health insurer Centene, which has invested in the ACA marketplace, as well as America's Health Insurance Plans, issued guarded responses to the executive order Monday.
"It is too early to speculate as this is just one step in what we know will be a process in the continued priority to find ways to correct the ACA," Centene said.
"There is no question the individual health care market has been challenged from the start," AHIP said ina statement. "The president said he would take swift action, and he has. We have been meeting with policymakers to offer our recommendations for a better marketplace, and we have found them to be highly engaged and focused on finding real solutions."
AHIP added that the industry still needs to create incentives to encourage people to buy plans and participate in the market, even if the individual mandate ios struck down. "This is essential to balancing the risk pool, which will help drive down premiums and costs for everyone," it said.
Both Cragun and Abrams agree that state control will be a significant theme of the Trump Administration and seen across Medicare, Medicaid and the individual market.
As to what will now happen with value-based care agreements, Cragun said there's not enough detail in the executive order to determine whether the Trump administration will roll back value-based purchasing, a program the ACA created that adjusts Medicare reimbursements based on hospital quality metrics. "
The executive order itself confers no new authority to agencies, it merely serves as a statement of the new administration's intent to roll back the ACA and directs agencies to begin the process," he said.
Cragun said it's important to realize that Trump's order notes that agencies must follow legal requirements and standard regulatory processes. Penalties and bonuses under the value-based purchasing are established in law, so any attempt at payment or penalty suspension would require regulatory action, a notice of proposed rulemaking and public comment period.
"While the Secretary could influence how payment adjustments are determined and possibly the distribution of adjustments, it's not clear that the Secretary could take action that would eliminate all payment adjustments under VBP," Cragun said.
"The executive order does not seem to imply a focus on VBP. Though that doesn't mean the Secretary couldn't choose to focus on VBP, it doesn't seem like a priority at this point."
Twitter: @SusanJMorse