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'Obamacare orphans' could be a huge problem for GOP health plan

President-elect Donald Trump (L) meets with House Speaker Paul Ryan on Capitol Hill, November 10, 2016.
Joshua Roberts | Reuters
President-elect Donald Trump (L) meets with House Speaker Paul Ryan on Capitol Hill, November 10, 2016.

As the Trump White House and Republican Congress start to flesh out their replacement plans for the Affordable Care Act, be prepared to hear a lot about "Obamacare orphans." These orphans have the potential to be one of the most lethal political time bombs in American history.

Most people will think of "Obamacare orphans" as the millions of people who got health coverage because of the ACA and will lose it thanks to the expected repeal of the law by Congress as well as major insurers like Humana pulling out of the Obamacare exchanges.

It looks like there could be a lot of them. Even if no one can agree on the exact number of people who have health insurance now because of Obamacare (estimates range from about 13 million to 22 million Americans) we're still talking about a lot of people. And you don't have to be a supporter of the ACA to admit a troublesome avalanche of Obamacare orphans is a real possibility.

Even President Donald Trump and top members of his team have addressed this fear by assuring the public a few times that no one will lose coverage under the Obamacare replacement plans his team and the GOP Congress are considering.

But even before Obamacare's presumed death, the U.S. is dealing with millions of de facto orphans because health insurance and health care are two different things. As millions of Americans who signed up for Obamacare plans found out the hard way over the last two years, being "covered" doesn't mean much if you can't afford a $6,000 deductible before your insurance plan really starts covering costs.

"Obamacare orphans have the potential to be one of the most lethal political time bombs in American history."

And being "covered" by an insurance plan or getting on Medicaid doesn't mean much either if you can't find a doctor who takes that insurance or accepts Medicaid. These are the first Obamacare orphans and anyone who doubts their size and political clout should remember that they and their stories played a big role in Republican election victories in 2014 and 2016.

And let's be fair, the number of Americans who were becoming health care orphans was already on the rise even before Obamacare became a word. Because health care is essentially a commodity and key parts of that commodity's supply have been in decline for more than a decade.

According to the Association of American Medical Colleges, there will be a nationwide shortage as great as 94,700 physicians in the coming decade with the majority of the need in primary care. We are also in the midst of a severe nationwide nursing shortage with some experts predicting there will be as many as one million needed empty nursing slots withing five years.

Dr. Eric Schnipper, owner/partner of Meridian Imaging Group and a Clinical Assistant Professor at NYU Langone Medical Center, says there are many political and regulatory reasons for this, but it's also simply about demographics.

"The physician population is aging as rapidly as the patient population, and retirements are outpacing newly minted physicians," Schnipper explains. He adds that increasing costs and requirements like cumbersome task of having to do hours of electronic health record data entry are driving even more doctors out of the profession.

The bottom line is that Obamacare, the impending death of Obamacare, and the shrinking supply of doctors that existed before Obamacare are all contributing and will continue to contribute to what could be tens of millions of Americans who already can't or soon won't be able to get health care reliably in the coming year or two.

You don't need to be a political genius to imagine just how damaging those many millions of people could be to the Trump administration and the Republican Congress if they are unable to craft a comprehensive plan to get them care.

America got a taste of the Obamacare orphans' potency earlier this month during the CNN health care debate between Senators Bernie Sanders and Ted Cruz. Cruz actually defeated Sanders with his better command of the facts and more potent rhetoric. But the real stars of the evening were the three people in the audience who had expensive health problems and spoke of their grave fears of losing their coverage if Obamacare is repealed.

These were real people who stoked the kinds of significant emotions that can turn elections around. Obamacare orphans with a microphone and a camera in front of them are a legitimate emotional and political hot potato the likes of which the nation hasn't seen since the vivid images of African Americans fighting for Civil Rights in the 1960s.

"So what will the Trump team and the GOP Congress have up their sleeves to improve real access to health care and avoid this potential public relations disaster? So far, they're making a lot of the same mistakes by focusing on insurance coverage instead of the root of the problem."

Here's what so many of President Trump's political enemies don't get: The American public really doesn't like politicians or the news media. And as long as those two groups remain the core of the anti-Trump movement, there are not likely to be enough detractors to vote him out of office. But if a large number of poorer and sicker ordinary Americans become the loudest critics of the White House or one of its major policies, all bets are off.

So what will the Trump team and the GOP Congress have up their sleeves to improve real access to health care and avoid this potential public relations disaster? So far, they're making a lot of the same mistakes by focusing on insurance coverage instead of the root of the problem.

Again, the big trap is conflating health insurance with health care. Even as the Obama team promised to get tens of millions of new people onto the health insurance rolls, not one part of the ACA did anything to address the need for more doctors, nurses, and health care facilities to treat them. In other words, all Obamacare did was successfully increase demand without even remotely doing anything to increase supply. It was the supply problem that made health care and the cost of health insurance more expensive in the first place. If health care was cheaper and more abundant, getting health insurance would be easier.

The Trump team and Congress need to attack those root problems head on. The costs and requirements to become and remain a doctor, especially a primary care physicians, are too high in America, period. The government can reduce them by relaxing, (not eliminating), many of its regulations on licensing doctors and providing them with some kind of tort reform.

It can also crack down on the accelerating rate of hospital consolidation that has left all of us, but especially people in rural areas, with fewer choices and almost no price competition in health care. Finally, it can institute the kinds of tax reforms that countries like Switzerland and Israel have instituted to boost price-deflating med tech, biotech and pharma innovations.

Another wise move would be to focus on the truly poorest and sickest Americans by allowing them and only them to join so-called "risk pools" that will not skimp on their care. If paying for that high quality care means reducing benefits and subsidies for healthier and wealthier Americans, so be it. Being able to provide better care to the most vulnerable people will provide the Republicans a very potent public relations tool of their own.

Otherwise, President Trump and the Republican Congress will be swamped with an endless stream of sympathetic and genuine Obamacare orphans all over TV news and the Internet in much of the coming year. And those orphans will be a very powerful weapon against him unless he and Congress can get them real health care, not just another new insurance plan.

Commentary by Jake Novak, CNBC.com senior columnist. Follow him on Twitter @jakejakeny.

For more insight from CNBC contributors, follow @CNBCopinion on Twitter.