Since the passage of the Affordable Care Act (Obamacare) seven years ago this month, Republican opponents have introduced dozens of replacement bills in an effort to undermine the legislation. Now that a Republican stands at the helm, surrounded by like-minded peers in Congress, rightwing politicians have the chance that they’ve been looking for to turn the tides when it comes to the American healthcare system. Whether you agree with Obamacare or not, the issue facing today’s legislators is how to ensure that the 20 million people who got covered under the ACA retain access to affordable health insurance.
On March 6, a new plan was laid out by congressional Republicans, one that drew immediate outrage from their friends on the left and concern from many of their fellow conservatives. This new bill – the American Health Care Act – seeks to replace the ACA with a hodgepodge of ideas collected over the last seven years. President Trump is attempting to fulfill a key campaign promise: to repeal and replace the Affordable Care Act. But this new plan is yet another in a long line of Republican efforts to destroy Obamacare legislation. How does it compare to what’s already on the table – and where do we go from here? Let’s take a look at the proposed plans to replace the ACA.
President Trump’s Campaign Promises
President Trump made bold declarations on the campaign trail, but he’s been a lot quieter regarding healthcare reform since taking office in January. Trump reiterated the mantra of the Republican Party: repeal and replace Obamacare. When questioned about the details of his plan for replacement, Trump dodged specifics. Trump’s campaign and transition sites laid out his plans for healthcare reform, but even these ideas were bare-bones bullet points rather than a fully formed plan. Here’s what we know about Trump’s hopes for healthcare:
- He wants everyone to have healthcare coverage.
- HSAs would be expanded and improved to make them more attractive to more families.
- Insurance could and would be sold across state lines.
- Consumers could write off the cost of premiums from their taxes.
- Medicaid would be funded via block grants instead of an open-ended match system.
- People with pre-existing conditions would still be covered.
Some of Trump’s ideas could help the economy and ensure that people remain covered, but many of his points lack sufficient detail to determine actual viability. For instance, he wants to grant everyone access to health insurance, but he does not say how this would happen or where the funding might come from. Likewise, health savings accounts (HSAs) appeal to a specific demographic, typically affluent or upper-middle-class families with the resources to save money in case of a medical emergency. Trump has not discussed how he would make these accounts viable for families who barely earn enough to cover everyday expenses.
A Better Way
Speaker of the House Paul Ryan has his own ideas about healthcare reform, which he proposed in a neatly packaged booklet called A Better Way. There are several good ideas in Ryan’s plan, but his approach to health care differs drastically from the standard Democrat view. It even differs from President Trump’s idea. Namely, Ryan believes in “access” over “universal coverage.” Instead of forcing people to buy health insurance, Ryan and the people who support A Better Way want to ensure that people gain access to health insurance. This small difference in phrasing makes a big difference when you’re talking about health insurance. As Bernie Sanders famously stated, you might have access to million-dollar homes, but that doesn’t mean you can afford to buy one. Under Ryan’s A Better Way plan:
- The emphasis would be on patient-centered care, meaning patients are in the control seat when choosing plans, providers and other aspects of healthcare.
- If you don’t have access to health insurance through your job or a government program (like Medicare or Medicaid), then you would be eligible for a portable tax credit that you could apply toward the cost of your healthcare coverage for the year. It would be based on age rather than income, with older people getting higher credits.
- People with pre-existing conditions would be directed into high-risk pools, where costs would be subsidized, separate from the general pool of other health insurance applicants.
- Funding would go toward health care advancements and the development of an effective, nationwide electronic medical records system to improve efficiency.
- Medicare will be strengthened to make it viable for future generations, particularly the retiring Baby Boomer generation.
Ryan also wants to push for “real medical liability reform,” a concept that dates back several decades to when medical malpractice suits first started driving up the cost of healthcare. A Better Way is a classic conservative approach to healthcare reform, and there are pros and cons to the ideas here. Trump has not commented much on the plan, and it’s not clear what his relative silence means on the issue.
The Cassidy-Collins Bill
Toward the end of January, a new bill was introduced by Republican Senators Susan Collins of Maine and Bill Cassidy of Louisiana that took a different, if somewhat bizarre, approach to healthcare reform. Called the Patient Freedom Act (or the Cassidy-Collins bill), this piece of legislation attempted to appease both sides of the spectrum by offering conservative ideas combined with the existing structure of the ACA. In essence, the Cassidy-Collins bill proposes to let individual states decide how they want to manage their own healthcare system. In a truly conservative move, the bill seeks to shift the power away from the federal government and into the hands of the states. However, the bill’s options seem to conflict with the overall message. Under the Patient Freedom Act, states could:
- Choose to reimplement the Affordable Care Act
- Create an alternative plan to the ACA based on federal funding
- Choose and alternative plan without federal financial assistance
Healthcare analysts are skeptical about this plan. Kaiser Family Foundation President Larry Levitt believes that the Cassidy-Collins bill keeps nearly all of the ACA intact, making it an interesting departure for a Republican-proposed plan. But there are key differences between this bill and the ACA, such as the fact that it eliminates the individual mandate, an important part of Obamacare. Like Ryan’s plan and Trump’s ideas, the Patient Freedom Act also retains protections for people with pre-existing conditions and the benefit that allows young adults up to age 26 to stay on their parents’ health plans.
American Health Care Act
It’s been nearly six weeks since President Trump was sworn in, and we finally have the official president-approved proposal for replacing the Affordable Care Act. How does it stack up against other proposals and campaign promises to date? Unfortunately, this latest proposal appears to take bits and pieces of popular Republican talking points and water them down into a confusing bill that nobody likes. Right after its release, several Republicans voiced strong opposition to the bill, not to mention outcry from Congressional Democrats over an apparent lack of information present in this new attempt at replacement. The 66-page American Health Care Act proposal outlines several proposals. Under the AHCA, we could expect the following:
- The individual mandate requiring health insurance would be eliminated.
- Young adults would be able to stay on their parents’ plans up until age 26.
- You might pay a 30 percent penalty fee on top of premiums if you let your health insurance lapse for more than two months.
- People with pre-existing conditions would still be granted guaranteed-issue coverage.
- Medicaid would remain as it is until 2020. Until then, the states that opted to expand their programs under ACA guidelines could keep enrolling new people. Starting in 2020, states would receive federal funding on a per-capita basis rather than an open-ended system.
Individual marketplaces may stay the same under the AHCA – at least right now. There hasn’t been official word on changing the structure of the exchange sites, but uncertainty about the future could disrupt the individual healthcare market as a whole.
There are several glaring problems with the bill aside from its vague outline for health care reform. First is that the Congressional Budget Office has not crunched the numbers on how much these proposals will cost. The bill also fails to show how many people would actually gain (or lose) coverage, and how much insurance might cost under this new system. From a legal standpoint, the bill has to jump through several high hoops to make it to the president’s desk, and given the slim majority that Republicans hold in the Senate, this is unlikely to happen with such a controversial proposal.
Several news outlets point out that the AHCA is just the first draft of what could be a very different bill once it goes through committee hearings and the appropriate government procedure. Commentators have questioned the viability of the bill, and some conservative pundits are just as outraged over features of the proposed law as their leftwing counterparts, but for different reasons. Important administration figures, including President Trump himself, fully support the AHCA. Over the next weeks and months, it will be interesting to see how this bill falls in line with others like it, and what kind of healthcare reform bill actually gets passed.