The Gutting of the Affordable Care Act

A number of people have asked me if I’m watching the impending annihilation of the Affordable Care Act as the new administration gears up to take office this week. The answer is yes, both because I’m interested in public health and health policy and because I get my own health insurance through the ACA. The assault on the law is already underway, and the consequences will be dire. For those of you who are concerned about what’s happening and what could happen but haven’t been following the news that closely, here’s a primer.

·      Although House Speaker Paul Ryan and President-elect Donald Trump have been crowing for months about repealing Obamacare, they don’t have enough votes to overturn the law outright. In the Senate, where Republicans have a 52-48 majority, they’d need 60 votes to overcome a Democratic filibuster. This means that eight Democrats would have to vote to repeal the ACA, which is extremely unlikely.

·      Since the Republicans lack a filibuster-proof majority in the Senate, they’ve chosen instead to gut major provisions of the ACA through a process called budget reconciliation. In short, this process allows them to get rid of sections of the law that are funded through the federal budget, but only those sections. They can reverse the Medicaid expansion. They can rescind the subsidies that most consumers receive to purchase insurance on the exchanges. They can also repeal the individual mandate to buy insurance. Both the House and the Senate voted last week to approve budget measures that will allow them to take these actions.

·      The Affordable Care Act is more than a program that allows individuals to purchase insurance plans through state exchanges. It contains a number of provisions that affect everyone who has health insurance, whether through an employer or on the individual market. These features of the law appear to be safe for now, because they’re untouchable through the budget reconciliation process. But it’s unclear whether they’ll ultimately be at risk. They include:

o   Free coverage of preventive services, including mammograms

o   Free coverage of birth control

o   Allowing young adults to remain on their parents’ health insurance until the age of 26

o   No denial of coverage for pre-existing conditions

o   An end to lifetime caps on how much an insurer pays to cover someone, which is crucial for those with conditions that are costly to treat

·      Republican leaders have proposed several ideas that they claim will provide people with better coverage at lower costs than Obamacare. They include:

o   Increased use of Health Savings Accounts. HSAs, however, are not the same as health insurance; they simply allow individuals to move pre-tax dollars into an account that can be used to pay for medical expenses out-of-pocket. They do nothing to ensure access or affordability.

o   Allowing insurance companies to sell policies over state lines. However, out-of-state insurers would probably just end up buying into existing networks of providers, so it wouldn’t actually improve anything. In addition, states have varied requirements for minimum coverage. New York State, for example, just passed a bill (which is not yet law) that provides free birth control coverage for women. Therefore, insurers would probably choose to sell their policies in states with the least, not most restrictive requirements.

·      Republicans, including Tom Price in his confirmation hearing today, have been asserting that no one will have their health insurance pulled out from under them when the ACA is gutted. They’ve said they will replace it with a plan that has people “beautifully covered,” to quote Trump. But the timing of Obamacare’s replacement is uncertain, as no one has offered a detailed blueprint of what it will look like, and health economists agree that it would be impossible to design a plan that offers better coverage and is cheaper for both individuals and the government than what we have now. An immediate repeal of the ACA’s individual subsidies would throw the insurance market into chaos, as companies would pull out to avoid the uncertainty that is sure to follow, since no one knows what the replacement plan will look like and when it will come.

The Affordable Care Act expanded health insurance coverage to 20 million Americans, although about 25 million more remain uninsured. Despite the law’s problems—high deductibles, rising premiums, small networks of providers, limited choice of plans in many parts of the country—removing its protections from those who need them strikes me as inhumane. The nonpartisan Congressional Budget Office released a report yesterday which said that a repeal of the ACA would cost 18 million people their insurance in the first year alone. We’ll probably never have single-payer health insurance in the U.S., as in every other industrialized country. But until we can implement a program that increases access while controlling costs, we have to work on improving what we’ve got, not destroying basic protections that are saving lives.