On March 23, 2010, the Patient Protection and Affordable Healthcare Act, also known as ACA or colloquially as Obamacare, was signed into law by President Obama. It passed with heavy Democratic support and no Republican support in the U.S. Congress, and for the past seven years, Republicans have aimed to repeal and replace the bill entirely, or at least parts of it.
In January 2017, President Trump was sworn in, and Republicans, having the majority of members in both the Senate and House of Representatives, saw their chance at finally replacing the ACA. In the Senate, Republicans currently have 52 seats and although rules usually require 60 out 100 Senate votes to pass legislation forward, the Republicans had a chance of passing a bill through with a simple majority under budget reconciliation rules until October 2017.
In between debates and policy proposals on tax reform, immigration, and guns, healthcare is still being hotly debated in Washington. Over the past year, several replacements to the ACA have been proposed and voted on, though none have received much support from the medical community. Here is a summary of the various bills that have been proposed, their provisions, the expected impact they would have, and the fate of each bill.
American Healthcare Act of 2017 / Better Care Reconciliation Act
Background: The first replacement plan for the ACA emerged in March 2017, a month and a half into Trump’s presidency. Amid criticism for trying to rush a bill through without paying attention to every detail and getting advice from major medical organizations, Republicans hoped to be able to use their majority in Congress to repeal and replace the ACA as soon as possible.
- Gives $2K to $4K a year in tax credits to those without insurance, in place of premium subsidies under ACA
- Repeals the Individual Mandate (the ACA requirement that most Americans buy insurance or be fined)
- Repeals the Employer Mandate (the ACA requirement of employers to insure their employees)
- Allows older adults to be charged up to 5x what younger adults are charged for the same treatment (Under Obamacare, the limit was 3x as much)
- Replace Medicaid Expansion (the ACA policy that expanded Medicaid programs to include more people in difficult financial situations) with a lump sum payout to states, for them to spend as they wish
- Requires insurers to charge 30% extra for people who haven’t been covered by insurance for a certain period of time
- Allows states to opt out of various provisions of ACA
- Gives states 138 billion over 10 years for healthcare costs
- 24 million more people would be uninsured by 2026.
- Important note: This means that, by 2026, 24 million more people will be uninsured relative to the predicted number of uninsured under the ACA. Also, the CBO notes that the majority of this difference would stem from people choosing not to buy insurance, either because of high premiums, or because the penalty for not doing so under the ACA would be gone.
- By 2026, average premiums for single policyholders in the nongroup market under the legislation would be roughly 10 percent lower than under current law. However, the change in premiums may largely depend on age; due to the new stipulation loosening restriction on pricing based on age, younger people could end up seeing lower premiums while old people see higher premiums.
- The federal budget deficit would see a $337 billion deficit reduction over 10 years
Fate: The first draft of the bill would be withdrawn after Congress failed to gather enough support. Later on, U.S. Representative Tom MacArthur (R-N.J.) wrote an amendment to the bill that would allow states to apply for additional waivers, including the ability to define their own essential health benefits. The new bill passed through the House. In the Senate, following a few additional amendments, the bill, now called the Better Care Reconciliation Act, was voted on in May 2017. It failed, 43-57.
Obamacare Repeal Reconciliation Act of 2017
Background: Although President Trump had promised in January that the ACA would be replaced rather than simply repealed, the Republicans were now noticing that replacement might take longer than expected, and opted in July 2017 to try a “repeal now, replace later” approach.
Provisions: This bill was a straight-up repeal of the ACA.
Impact: The CBO reported that if the ACA were repealed without replacement:
- Up to 32 million more people would be uninsured by 2026 if no replacement were found.
- There would be a 473 billion reduction in the federal budget deficit over 10 years.
Fate: This bill was voted down 45-55 in the Senate.
Background: In July 2017, after failing to outright repeal the ACA, the Republican Senate leadership drafted a bill that would only repeal certain parts of the bill, hoping to make some progress on replacing the ACA.
- Repeals Individual Mandate and Employer Mandate
- Suspends Medical Device tax
- Allows states to waive certain ACA provisions
Impact: According to the CBO:
- There would be 16 million more uninsured than under the ACA by 2026.
- Premiums in the individual market would increase by 20 percent compared to current law in all years between 2018 and 2026.
- The Federal deficit would be reduced by $135.6 billion over ten years.
Fate: This bill was voted down 49-51 in the Senate.
Background: In September 2017, Senators Lindsey Graham and Bill Cassidy introduced a new amendment to the original American Healthcare Act in order to garner more support in congress
- Repeals Medicaid Expansion and reallocates it as a lump sum payout to states
- Repeals the ACA’s Individual and Employer Mandates, income-based tax credits, and cost sharing subsidies for insurers to cover low-income customers
- Allows states could apply for waivers to determine their own Essential Health Benefits
- Allows people to contribute more to their Health Savings Accounts
Impact: According to the CBO:
- $133 billion deficit reduction over 10 years
- No time for a full comprehensive report but:
- “the number of people with comprehensive health insurance that covers high-cost medical events would be reduced by millions”
As the bill gained traction, several major medical organizations came out in opposition to the bill, believing that it would negatively impact patients’ access to affordable and adequate care.
Fate: The bill again failed to gain support from 50 Republicans, and was withdrawn.
Medicare For All:
Background: Senator Bernie Sanders, a self-described Democratic Socialist, has long been a proponent of a single-payer, universal healthcare plan. Among all the GOP bills going through congress, Sanders decided to release a very different bill in order to shift the conversation on healthcare.
- Single Payer: States and insurance companies no longer are part of carrying healthcare costs, as it is all covered by the federal government. As such, other employers would be barred from offering other plans, with the exception of the U.S. Department of Veteran’s Affairs and the Indian Health Services for Native American tribes
- Expands Medicare coverage to all Americans within 4 years
- Expands Medicare coverage to areas such as dental and vision care: these are not typically provided by insurers and are also not guaranteed by other countries’ single-payer plans, like those of Canada, Australia or the Netherlands
- The only out-of-pocket cost Americans need to pay relating to medical care would be for prescription drugs
- Insurers don’t set prices; and the government foots the bill
Impact: There has not been a CBO report, as the bill doesn’t have enough support in Congress to warrant it. The medical community is split on their reactions to the bill; the law may be a boost for primary care providers and nurses, and a problem for specialists based on how it evens the playing field for reimbursements. The main problem with the law is financing it; the Urban Institute estimates the federal expenditures necessary for the bil at $32 trillion over 10 years, and gaining that revenue would be very difficult.
Fate: The bill has essentially no chance of making any progress in the Senate; Sanders himself admits this, as the bill has little support even among congressional Democrats. Sanders says the purpose of the legislation is to “force a conversation” about what kind of healthcare goals the US should have.
Senators Lamar Alexander, R-Tenn. and Patty Murray, D-Wash. have drafted the first bipartisan healthcare bill of the year. It is meant to be a short-term solution, to stabilize insurance markets and fund federal subsidies for the next two years. It has gained the support of 10 governors from both parties, and dozens of healthcare organizations including the American Medical Association. The bill would ideally benefit premiums for 18 million Americans. The fate of this bill is uncertain, and it is not clear whether it will be brought to a vote, and Trump has not been clear as to whether he supports it or not. But even if it does pass, it will not be a long-term solution to the healthcare debacle.
At this point, if new major healthcare legislation is to be passed, it will probably need to be bipartisan, as the rules allowing a simple majority have expired for the year. Bipartisan legislation may take some time under the current political climate, but both sides agree that the US healthcare system needs reform, so we can expect to see a good deal of debate over the next few years.