Repealing the Affordable Care Act without a Replacement: The Risks to American Health Care.
Barack Obama, J.D.
(from: http://www.insurancereformwatch.org/laws/obama_aca.shtml)
Health care policy often
shifts when the country's leadership changes. That was true when
I took office, and it will likely be true with President-elect
Donald Trump. I am proud that my administration's work, through
the Affordable Care Act (ACA) and other policies, helped millions
more Americans know the security of health care in a system that
is more effective and efficient. At the same time, there is more
work to do to ensure that all Americans have access to high-quality,
affordable health care. What the past 8 years have taught us is
that health care reform requires an evidence-based, careful approach,
driven by what is best for the American people. That is why Republicans'
plan to repeal the ACA with no plan to replace and improve it
is so reckless. Rather than jeopardize financial security and
access to care for tens of millions of Americans, policymakers
should develop a plan to build on what works before they unravel
what is in place.
Thanks to the ACA, a larger share of Americans have health insurance
than ever before [1]. Increased coverage is translating
into improved access to medical care-as well as greater financial
security and better health. Meanwhile, the vast majority of Americans
still get their health care through sources that predate the law,
such as a job or Medicare, and are benefiting from improved consumer
protections, such as free preventive services.
We have also made progress in how we pay for health care, including
rewarding providers who deliver high-quality care rather than
just a high quantity of care. These and other reforms in the ACA
have helped slow health care cost growth to a fraction of historical
rates while improving quality for patients. This includes better-quality
and lower-cost care for tens of millions of seniors, individuals
with disabilities, and low-income families covered by Medicare,
Medicaid, and the Children's Health Insurance Program. And these
benefits will grow in the years to come.
That being said, I am the first to say we can make improvements.
Informed by the lessons we've learned during my presidency, I
have put forward ideas in my budgets and a July 2016 article [2] to address ongoing challenges-such
as a lack of choice in some health insurance markets, premiums
that remain unaffordable for some families, and high prescription-drug
costs. For example, allowing Medicare to negotiate drug prices
could both reduce seniors' spending and give private payers greater
leverage. And I have always welcomed others' ideas that meet the
test of making the health system better. But persistent partisan
resistance to the ACA has made small as well as significant improvements
extremely difficult.
Now, Republican congressional leaders say they will repeal the
ACA early this year, with a promise to replace it in subsequent
legislation-which, if patterned after House Speaker Paul Ryan's
ideas, would be partly paid for by capping Medicare and Medicaid
spending. They have yet to introduce that "replacement bill,"
hold a hearing on it, or produce a cost analysis-let alone engage
in the more than a year of public debate that preceded passage
of the ACA. Instead, they say that such a debate will occur after
the ACA is repealed. They claim that a 2- or 3-year delay will
be sufficient to develop, pass, and implement a replacement bill.
This approach of "repeal first and replace later" is,
simply put, irresponsible- and could slowly bleed the health care
system that all of us depend on. (And, though not my focus here,
executive actions could have similar consequential negative effects
on our health system.) If a repeal with a delay is enacted, the
health care system will be standing on the edge of a cliff, resulting
in uncertainty and, in some cases, harm beginning immediately.
Insurance companies may not want to participate in the Health
Insurance Marketplace in 2018 or may significantly increase prices
to prepare for changes in the next year or two, partly to try
to avoid the blame for any change that is unpopular. Physician
practices may stop investing in new approaches to care coordination
if Medicare's Innovation Center is eliminated. Hospitals may have
to cut back services and jobs in the short run in anticipation
of the surge in uncompensated care that will result from rolling
back the Medicaid expansion. Employers may have to reduce raises
or delay hiring to plan for faster growth in health care costs
without the current law's cost-saving incentives. And people with
preexisting conditions may fear losing lifesaving health care
that may no longer be affordable or accessible.
Furthermore, there is no guarantee of getting a second vote to
avoid such a cliff, especially on something as difficult as comprehensive
health care reform. Put aside the scope of health care reform-the
federal health care budget is 50% bigger than that of the Department
of Defense [3]. Put aside how it personally
touches every single American-practically every week, I get letters
from people passionately sharing how the ACA is working for them
and about how we can make it better. "Repeal and replace"
is a deceptively catchy phrase-the truth is that health care reform
is complex, with many interlocking pieces, so that undoing some
of it may undo all of it.
Take, for example, preexisting conditions. For the first time,
because of the ACA, people with preexisting conditions cannot
be denied coverage, denied benefits, or charged exorbitant rates.
I take my successor at his word: he wants to maintain protections
for the 133 million Americans with preexisting conditions. Yet
Republicans in Congress want to repeal the individual-responsibility
portion of the law. I was initially against this Republican idea,
but we learned from Massachusetts that individual responsibility,
alongside financial assistance, is the only proven way to provide
affordable, private, individual insurance to every American. Maintaining
protections for people with preexisting conditions without requiring
individual responsibility would cost millions of Americans their
coverage and cause dramatic premium increases for millions more
[4]. This is just one of the many
complex tradeoffs in health care reform.
Given that Republicans have yet to craft a replacement plan, and
that unforeseen events might overtake their planned agenda, there
might never be a second vote on a plan to replace the ACA if it
is repealed. And if a second vote does not happen, tens of millions
of Americans will be harmed. A recent Urban Institute analysis
estimated that a likely repeal bill would not only reverse recent
gains in insurance coverage, but leave us with more uninsured
and uncompensated care than when we started [5].
Put simply, all our gains are at stake if Congress takes up repealing
the health law without an alternative that covers more Americans,
improves quality, and makes health care more affordable. That
move takes away the opportunity to build on what works and fix
what does not. It adds uncertainty to lives of patients, the work
of their doctors, and the hospitals and health systems that care
for them. And it jeopardizes the improvements in health care that
millions of Americans now enjoy.
Congress can take a responsible, bipartisan approach to improving
the health care system. This was how we overhauled Medicare's
flawed physician payment system less than 2 years ago. I will
applaud legislation that improves Americans' care, but Republicans
should identify improvements and explain their plan from the start-they
owe the American people nothing less.
Health care reform isn't about a nameless, faceless "system."
It's about the millions of lives at stake-from the cancer survivor
who can now take a new job without fear of losing his insurance,
to the young person who can stay on her parents' insurance after
college, to the countless Americans who now live healthier lives
thanks to the law's protections. Policymakers should therefore
abide by the physician's oath: "First, do no harm."
References:
1.
The
Economic record of the Obama administration: Reforming the health
care system.
Washington, DC: Council of Economic Advisers, 2016.
2. Obama B. United
States health care reform: Progress to date and next steps. JAMA
2016;316:525-32.
3. The
President's budget for fiscal year 2017. Washington, DC: Office of
Management and Budget, 2016
4. Options
for reducing the deficit: 2017 to 2026. Washington, DC: Congressional
Budget Office, 2016.
5. Blumberg LJ, Buettgens M, Holahan J. Implications
of partial repeal of the ACA through reconciliation. Washington,
DC: Urban Institute, 2016.
________________________________________
Mr. Obama was President of the United States when this article
was posted on January 6, 2017. The New
England Journal of Medicine originally published this article, which
is not copyrighted.
Obama
cautions about Affordable Care Act repeal (Consumer Health Digest #17-02
- January 8, 2017)
The New England Journal of Medicine has published outgoing President
Barack Obama's view that repealing the Affordable Care Act without
a clear and suitable replacement would pose severe risks to tens
of millions of Americans. It states:
[The] approach of "repeal first and replace later"
is, simply put, irresponsible-and could slowly bleed the health
care system that all of us depend on. . . . . If a repeal with
a delay is enacted, the health care system will be standing on
the edge of a cliff, resulting in uncertainty and, in some cases,
harm beginning immediately. Insurance companies may not want to
participate in the Health Insurance Marketplace in 2018 or may
significantly increase prices to prepare for changes in the next
year or two, partly to try to avoid the blame for any change that
is unpopular. Physician practices may stop investing in new approaches
to care coordination if Medicare's Innovation Center is eliminated.
Hospitals may have to cut back services and jobs in the short
run in anticipation of the surge in uncompensated care that will
result from rolling back the Medicaid expansion. Employers may
have to reduce raises or delay hiring to plan for faster growth
in health care costs without the current law's cost-saving incentives.
And people with preexisting conditions may fear losing lifesaving
health care that may no longer be affordable or accessible.
The full text of the article-which is not copyrighted-is posted
to Insurance Reform Watch. Along the same lines, University of
North Carolina professor Jonathan Oberlender, Ph.D., noted that
"Talking about repealing the ACA is much easier than actually
repealing and replacing it" and that president-elect Donald
Trump's reform vision "remains largely a mystery." [Oberlender
J. The
end of Obamacare. New England Journal of Medicine 376:1-3,
2017]
Proposed "Obamacare" cuts pose huge financial risk to
millions (Consumer
Health Digest #17-13 - March 19, 2017)
Although President Trump and other Republican leaders have pledged
to "repeal"or "repeal and replace" major provisions
of the Patient Protection and Affordable Care Act, this cannot
be done without harming huge numbers of American citizens. The
Congressional
Budget Office estimates that by 2026, the recently proposed
American
Health Care Act of 2017 (H.R. 277) would result in 52 million
Americans being uninsured, compared with 28 million who would
lack health insurance that year under the current law. Wikipedia
has an excellent political analysis.
Trump and Harris contrasted on health care policy (Consumer Health
Digest #24-32 - August 11, 2024)
KFF, an independent source of health policy research and journalism,
has provided a side-by-side analysis of the positions of the Republican
and Democratic presidential nominees on the Affordable Care
Act, Medicaid, abortion, contraception, LGBTQ health, gun violence,
public health, prescription drug prices, Medicare, health care
costs, mental health, opioid use disorders, long-term care, global
health, and immigrant health coverage. [Compare
the candidates on health care policy. KFF, Aug 8, 2024] The
analysis will be updated as new information and policy details
emerge throughout the campaign.
page
created: March
5th 2017 and last updated:
August
20th, 2024