The Trump administration has come out with a 365-page notice that shows how the U.S. major medical insurance market could look in 2019 — if that market still exists, if the current laws stay about the same, and if the administration tries to keep public health insurance exchange program going.

The Centers for Medicare & Medicaid Services (CMS) maps out the future in a draft set of Affordable Care Act (ACA) benefit and payment parameters for 2019.

In the draft notice, CMS officials suggest that agents and brokers might:

• Offer plans that are a little leaner than the plans available today.

• Have an easier time finding policies compatible with health savings accounts, and policies based on value-based insurance design principles.

• Face fewer, but tougher, navigators.

• Have a little bit easier time collecting commissions.

President Donald Trump and Republicans in Congress are trying to replace the ACA. But CMS officials based the parameters draft on the statutes now in effect. They assume, as a given, that the ACA public exchange programs will exist, that the federal government will continue to pay income-based premium tax credit subsidies, and even that the federal government will continue to make cost-sharing reduction subsidy payments to insurers.