Obamacare / ACA

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This is a collaborative knowledge base; feel free to propose edits/additions that you believe are important for others to know. Contributions will be reviewed and approved based on quality and accuracy.

Recent Updates

  • 2/25/2017 More than 22,000 retired coal miners could lose their health care in April unless Congress intervenes to fund the United Mine Workers. [2]
  • 2/23/2017 Alaska Sen. Lisa Murkowski (R) says she won't vote to repeal Medicaid expansion or to defund Planned Parenthood as part of efforts to repeal the ACA. [3]
  • 2/17/2017 A Republican plan for replacing the Affordable Care Act would offer tax credits to all Americans purchasing coverage on the individual market and would not allow women to use those subsidies to buy plans that paid for abortion. This could cause many carriers to eliminate abortion coverage in the individual market. [4]
  • 2/16/2017 The Trump Administration has released a list of proposed rules that will try to shift the ACA to a "competitive private health insurance market" These rules (which have been influenced by health lobbyists) include: placing vulnerable enrollees into high risk pools, allowing for companies to charge higher premiums to older individuals, making it easier to discriminate against older individuals and people with special needs, attacking fees that help Americans shop for a new health insurance plan. [5]
  • 2/16/2017 HHS Department proposes a rule[6][7] to cut in half the time when people can sign up for coverage under Obamacare and reduce special enrollment periods that have allowed people to sign up for coverage outside the regular window.
  • 2/15/2017 As a consequence of Trump's executive order, the IRS says it will not reject tax forms from people who fail to answer whether they had health insurance[8], making it much harder to enforce Obamacare's individual mandate.
  • 2/13/2017 The Freedom Caucus of the Republican Party has voted to oppose and ACA repeal legislation if it is not as strong as the 2015 budget reconciliation measure blocked by President Obama. [9]

How You Can Resist
How You Can Resist

Actions Taken by the Federal Government
Actions Taken by the Federal Government

Legislative Actions[edit]

Legislation that Supports Equity and Justice

  • H.R. 179 / S. 175 The Miners Protections Act of 2017 is legislation that would ensure that the federal government and coal operators honor their obligation of lifetime pensions and health benefits to retired miners and their families.

Harmful Legislation

  • On 1/12/2017, the Senate voted to pass the budget resolution 51-48, and on 1/13/2017 the House voted to pass the resolution 227-198 [13][14]. This budget resolution outlined broad goals (e.g., cut $1 billion from the deficit over the next 10 years). Now, committees (smaller issue-focused groups within Congress will have until January 27 to draft laws and pass them within the committees for consideration by the entire Congress. These laws would specifically repeal elements of Obamacare.[15].
  • On 1/5/2017[16], the Senate took the first procedural vote on a budget measure that would be used as a way for Republicans to repeal Obamacare through a process called Budget Reconciliation.[17] The procedural vote passed 51-48, which allowed the Senate to consider the budget bill that includes the repeal of Obamacare.[18]
Key steps in GOP strategy to repeal Obamacare[1]

See also the State and Local Pages for state-by-state legislative tracking.

Executive / Administrative Actions[edit]

  • 2/16/2017 HHS Department proposes a rule [19][20] to cut in half the time when people can sign up for coverage under Obamacare and reduce special enrollment periods that have allowed people to sign up for coverage outside the regular window.
  • 2/15/2017 As a consequence of Trump's executive order, the IRS says it will not reject tax forms from people who fail to answer whether they had health insurance[21], making it much harder to enforce Obamacare's individual mandate.
  • 2/06/2017 One of President Trump's picks for Commissioner of Food and Drugs (FDA head) is Bill O'Neill, who is likely to shorten the approval process for food and drugs on the way to the market. O’Neill has argued that companies should not have to complete lengthy clinical trials before selling products to consumers. Critics say that innovative companies will have a hard time distinguishing their products from less effective/sham products hitting the market. [22]
  • 1/31/2017 After meeting with pharmaceutical lobbyists, President Trump withdraws support for allowing Medicare to negotiate bulk drug prices, calling negotiations "price fixing." Trump also promised to slash regulations at the Food and Drug Administration in an effort to make manufacturing easier in the United States. [23] [24]
  • 1/20/2017 Donald Trump signs an executive order that directs the Secretary of Health and Human Services and the heads of other agencies to "waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the (Affordable Care) Act that would impose a fiscal burden" on states, cities, and all parties involved in the health-care system. In addition, department heads are directed to "provide greater flexibility to States and cooperate with them in implementing health-care programs." [25] According to health policy experts, this order will have little tangible effect.[26]

Projected Impact
Projected Impact

Replacing Obamacare[edit]

  • 2/16/2017: House Republicans released an outline of an Obamacare replacement plan. While details will be subject to negotiation as the proposal advances, an analysis of their proposed plan finds it would disproportionately benefit the wealthy, while cutting benefits for other populations:
Impact of Obamacare replacement plan

Repealing Obamacare[edit]

Repealing Obamacare through Budget Reconciliation would have the following impact:[27]

Loss of Coverage, Loss of Jobs, Increased Costs

  • At least 43,956 people will die each year as a result of repealing Obamacare[28].
  • 29.8 million Americans will lose their health insurance.
  • While there is no agreement in the GOP on a replacement plan,[29] the plan proposed by the new Secretary of Health and Human Services, Tom Price, eliminates Medicaid coverage for 15,000,000 low-income Americans [30].
  • The Congressional Budget Office estimates that, if Obamacare is repealed, the uninsured population would "increase by 18 million in the first new plan year" and that premiums for those buying individual insurance "would about double by 2026." [31]
  • 3 million jobs will be lost by 2021 as a result of ACA repeal.[32]
  • Obamacare exchanges may crash without an immediate replacement, even if the GOP follows though on its plan to include a delay on when the repeal goes into effect. [33]
  • The repeal-and-delay legislation could add roughly $725 to $900 to the 2018 average annual premiums for 27-year-olds in states using the federal exchanges (HealthCare.gov). [34]

Demographics of Those Impacted

  • 82% will be working class.
  • 44% will be people of color.
  • Repeal will disproportionately impact Trump voters.[35]
  • 71 million people, most of them women, could lose access to free preventative services, including mammograms, immunizations, and affordable contraception (i.e., birth control).[36] This chart from Business Insider shows how much IUDs and mammograms will cost in your state if the ACA is repealed.
  • A Republican plan for replacing the ACA would offer tax credits to all Americans purchasing coverage on the individual market and would not allow women to use those subsidies to buy plans that paid for abortion. This could cause many carriers to eliminate abortion coverage in the individual market. [37]
  • Prior to the ACA's ban on gender rating, women in the U.S. could pay up to 57% more for the same coverage compared to men; an ACA repeal could bring back that coverage gap.[38]
  • 55- to 64-year-olds, even if they are healthy, will see health-care costs increase dramatically, by up to 10 times, and nearly 20% of people age 55 to 64 could become uninsured.[39]

Effect on People with Disabilities

  • Eliminating Medicaid expansion would disproportionately impact Americans with disabilities, 10 million of whom are currently covered by Medicaid.[40] Furthermore, repealing Obamacare would allow insurers to discriminate against someone based on a pre-existing condition if they do not maintain "continuous coverage," which would also disproportionately harm people with disabilities.[41]
  • Cuts to Medicaid also impact people with disabilities' ability to get the resources they need to live and work in their communities instead of being warehoused in institutions.[42] [43]
  • 2.8 million people with substance abuse issues will lose coverage.[44]
  • 1.25 million people with mental health issues will lose coverage, including many veterans.[45]
  • Under the ACA, mental health services qualify as an "essential health benefit" that marketplace insurers must cover. If this portion of the act is repealed and insurers are no longer required to cover mental health treatment, patients with mental illnesses may be forced into the private marketplace and priced out of care.[46]
  • Medicaid, the federal insurer for low-income Americans, is the nation's single largest payer for mental health services.[47] Medicaid covers 70 million people per year, and through the ACA Medicaid expansion program, 10 million additional Americans gained access to care. 31 states implemented Medicaid expansion under the ACA, extending mental health services to low-income citizens. Nearly one-third of patients who gained access to Medicaid under the ACA expansion live with a severe mental illness.[48] Trump's plan to delegate Medicaid administration to the states through block grants may spell disaster for low-income people with mental illness, as states gain the flexibility to cut essential mental health services from coverage once they are free from federal oversight.[49]
  • The Medicare Trust Fund, which was extended by a decade, will have several years reduced from its expected life.[50]

Public Health Impacts

  • Patient-Centered Research Funding would be eliminated. This would impact PCORI, the Patient-Centered Outcomes Research Institute, which currently funds millions of dollars for research across the nation, including a cohort of over 10 million patients. This type of research puts patients at the center of research, making them part of the team, as opposed to having scientists making all the decisions. [51]
  • Obamacare/ACA directs millions of dollars to urban public health initiatives that address everything from lead poisoning to health-care access. If Obamacare is repealed, the Prevention Fund that pays for these could be eliminated along with it, which could mean vanishing resources for thousands of essential programs around the country.[52]
  • The Affordable Care Act mandated coverage of cervical cancer detection services—along with all preventive care—at no cost to the patient. But the Republican-controlled Congress and White House have already taken steps to dismantle the ACA, and the fate of preventive care is uncertain as a result. If racial disparities in cervical cancer death rates boil down to unequal access to quality detection services and subsequent treatment, then patients who struggle to afford care are bound to be worse off under repeal.[53]
  • The proposal to roll back the Medicaid expansion, backed by many Congressional Republicans, threatens to strip coverage—and thereby the ability to obtain detection services and treatment—from the patients who arguably need it the most. Some 11 million low-income individuals will lose access to Medicaid under this proposal, and black women are more likely to be affected. [54]

Tax Cuts for the Wealthy and Pharmaceutical Companies

  • $350 billion would be added to the deficit and $9 trillion added to the debt, while the super-wealthy (those with incomes above $1 million) would get a tax break of $57,000.[55]
  • Costs to hospitals would increase by $1.1 trillion over the next ten years as uncompensated care increases, since more people without health coverage would be unable to afford medical treatment.[56]
  • Tax cuts for millionaires. Households making more than $1 million would receive tax cuts averaging more than $50,000 apiece in 2025. ACA repeal would raise taxes on about 7 million low- and moderate-income families due to the loss of their premium tax credits that help them buy health coverage.[57]
  • Taxes that fall on high-income earners will be repealed. The repeal of the Hospital Insurance tax and the Medicare tax would make millionaires the overwhelming beneficiaries of repealing these two taxes: they would reap 80 percent of the tax cuts in 2017. The 400 highest income earners would receive a tax cut that would total about $2.8 billion a year.[58]
  • Health insurers and manufactures receive tax cuts as well. The tax cut on drug companies, health insurers, and medical device manufacturers would reduce revenue by $180 billion by 2025.[59]
  • A repeal could also encourage tax avoidance. A full repeal would eliminate ACA provisions that help prevent business tax shelters and raise penalties on tax avoiders.[60]
  • Check out State and Local Pages to learn about impacts for your state.

Trump / GOP Strategy
Trump / GOP Strategy

The Basics

  • Since a full repeal of Obamacare, also known as the Affordable Care Act, would need 60 votes in the Senate to overcome a Democratic filibuster,[61] which is unlikely to happen, Republicans appear to have adopted a "repeal and delay" strategy focusing on repealing much of the law in Trump's first 100 days through Budget Reconciliation.[62] This would make the repeal go into effect between 2019 and 2021[63], giving them time to pass a replacement (which they have not yet decided upon).
  • This strategy of using Budget Reconciliation would only require 50 Senate votes to repeal much of Obamacare, though it would still take 60 votes to repeal all of Obamacare or to pass a replacement. [64]
  • Using this approach, Republicans could eliminate Obamacare's Medicaid expansion, federal financial assistance for Marketplace coverage (premium tax credits and cost-sharing reductions), and individual and employer mandates. Republicans can also use budget reconciliation to achieve their intended goal of converting Medicaid into a block grant (rather than an open-ended entitlement), meaning that it would be easier for states to cut critical health-care services to vulnerable and marginalized populations.[65]
  • Republicans cannot use this approach to eliminate the insurance market reforms (including the nongroup market’s guaranteed issue, the prohibition on excluding people with preexisting condition, modified community rating, essential health benefit requirements, and actuarial value standards).[66]

Proposed GOP plan/Assessment

A new proposed GOP draft bill and a leaked revision (proposed on 02/16/16 by Speaker Ryan) does the following[67] [68]:

  • Employs the use of individual refundable tax credits, paid out regularly, to help with costly monthly premiums. These credits will be based on age not income. [69]

This action would replace the subsidies offered by the ACA and would likely provide relief to fewer people. Health Secretary Tom Price once proposed a yearly credit of $2,000 for those age under 30 and $4,000 for those age 60 and up. $2,000 is a little over half of the amount needed by a young person making minimum wage. [70]

  • HSAs or Health Savings Accounts are a tax free way to save for healthcare. The maximum contributions will be increased to $13,000 per family. HSAs are used to pay for medical expenses, and under this plan these credits will no longer increase based on need but will increase based on an individuals age.[71]

The issue with HSA is that they are of little help to low-income people, who have less disposable income to deposit into these accounts and to sick people who are likely to use up their funds quickly.

  • Changes Medicaid into a block grant. States will receive a fixed lump sum of funding, rather than paying a percentage of health expenditures in each state. The program will transform it from a guaranteed benefit for low-income Americans and people with disabilities to an annual lump sum payment to states that is not tied to the need for services.

If an increasing number of people needs these healthcare services, a block grant will not adjust to meet rising demand. [72]. One study found that this disruptive change in Medicaid could kick 20.5 million people off of Medicaid in 10 years. [73]

  • High risk pools are being proposed as well. In this case, sicker people will be isolated into their own pool of health insurance policies.

In theory, the pools seem to be bringing down cost for those who are healthier. Unfortunately it drives up the price of insurance for those who are sick. One study placed the cost of adequately funding these pools at $178.1 billion a year. [74]. Health Secretary Tom Price plans to fund these pools with $1 billion a year ($ that states could spend in other ways), which will force many people who need insurance to drop it. [75]

  • To soften the blow, one of the ways Republicans plan to pay for this repeal effort is by limiting the size of the tax breaks employers and workers receive on their health plans.[76]. This new taxation would draw from 38 million workers, generating about $250 billion in revenue to help with reducing the burden high risk pools to insurers. [77] [78]
  • The House Republican/Secretary Price plan is not helpful to those who are older, poorer and sicker. The plan eliminates the restriction on charging older people more than 3x the amount charged to young people. This would obviously increase the number of younger healthier people in the market, while charging higher unfettered premiums to older people. This is antithetical to the goal of Obamacare, to expand coverage for those who really needed.

What's Missing

  • The plan, thus far, has included all of the benefits and none of the costs of this plan. It also does not offer any projected figures on how many people will gain/lose coverage.
  • The individual mandate is likely to be repealed and this new plan does not incentivize younger healthier people to buy insurance and stay insured.
  • Now there is a name for what they would replace the individual mandate with - 'Continuous Coverage Incentive'. Little is known about this plan other than the fact that it punishes people for waiting until they get sick to buy health insurance. [79] and that if there is a lapse in coverage, insurers could charge up to 130 percent of the standard rate for the first year of coverage. [80]

Vulnerabilities in Their Strategy
Vulnerabilities in Their Strategy

  • 'An NBC News/Wall Street Journal poll found that public support for the ACA has never been higher (as of 02/09/2017). A Pew Research Center poll found that 60% of Americans say that the government should ensure health coverage for everyone. [81]
  • A poll (on 02/08/2017) found that 35% of respondents either think Obamacare and the Affordable Care Act are different policies or aren’t sure whether they’re different policies. It also found that 53% of Republicans don’t know that repealing Obamacare would mean repealing the Medicaid expansion. [82]
  • House conservatives, frustrated by GOP leadership’s slow and tentative approach to replacing the Affordable Care Act, have gotten behind legislation that would repeal most of the law and move millions of Americans Health Savings Accounts (HSAs). The most conservative wing of the GOP, the Freedom Caucus, has promised to oppose any ACA repeal bill that isn't as strong as the vetoed 2015 budget reconciliation measure passed by the GOP. This move widens the divide in the GOP as to how Obamacare will be dismantled and will likely slow down the process. [83]
  • Because Republicans are relying on an obscure parliamentary technique ("Reconciliation") to pass repeal by a bare majority, they have less flexibility on timing. The budget reconciliation process that they've slated for Obamacare repeal will expire when they move on to reconciliation for next year's budget.[84]
  • If health-care repeal stalls, they might have to pull off tricky legislative maneuvers to buy more time, or they might have to try to accomplish tax reform and health care together in one bill. The strategy for Democrats is to hold up the process, to make this reconciliation move more difficult.[85]
  • Most Republicans support turning Medicaid into a block program. This means that states will have more power in deciding how Medicaid dollars gets spent. The problem is that this would require massive cuts to the current program, throwing tens of millions of people off Medicaid. This would cause a huge backlash to Republicans' already unpopular repeal efforts.[86]
  • Republicans are struggling to construct a consistent message around ACA repeal efforts. Two prominent Republicans---Senators Orrin Hatch (R-UT) and Lamar Alexander (R-TN)---have made public statements signaling their willingness to repair the ACA incrementally, rather than fully repealing the law quickly. Both senators still support removing ACA provisions, but they are using the word "repair" to soften public backlash. Alexander favors a go-slow repeal process, while Hatch support a quick repeal while working on repairing the system. House Speaker Paul Ryan remains in favor of repeal, stating that repairing the law is the same thing as replacing it. This lack of consistent messaging will make Obamacare the issue that most divides and polarizes the Republican Party, particularly the relationship between Congressional Republicans and the White House. Disagreements, as with any other landmark legislation, will likely slow down repeal efforts.[87]

  • There are currently 52 Republican US Senators. If all Democrats vote against a repeal, it will take at least 3 Republicans to join them to stop it from being passed.
  • 4 Republican Senators---Lamar Alexander (Tennessee), Bob Corker (Tennessee), Tom Cotton (Arkansas), and Susan Collins (Maine)---have expressed concerns [88][89] about repealing Obamacare without a replacement already worked out, and one Republican Senator---Rand Paul (Kentucky)---has said that he'll oppose legislation to repeal Obamacare because it would increase the federal deficit.[90]
  • According to FiveThirtyEight.com, the Republican Senators most likely[91] to oppose Trump are Susan Collins (Maine), John McCain (Arizona), Rand Paul (Kentucky), Rob Portman (Ohio), and Lisa Murkowski (Alaska).
  • There are 20 Republican senators currently representing states that have expanded Medicaid under Obamacare.[92] Their states will be particularly impacted by a repeal, and they may be more willing to vote against it because a repeal might hurt their chances of reelection.

Past Updates
Past Updates

  • 2/10/2017 Tom Price is confirmed as health secretary after the Senate voted 52 to 47 early Friday. This potentially puts him in charge of the dismantling of Obamacare/the ACA. [93]
  • 2/09/2017 The Trump Administration has removed all positive reference to Obamacare online, including language that credits the law for giving consumers more control over their health care as well as descriptions of available services. [94]
  • 2/06/2017 Drafts of Trump Administration proposals include making changes to the ACA in order to convince insurers to remain in the marketplaces while Congress drafts a replacement plan. These proposals may limit enrollment and increase costs for older customers. [95]
  • 2/01/2017 After suspending committee rules, Senate Republicans voted (14-0) to move HHS nominee Tom Price's nomination to a full Senate floor vote. [96]
  • 1/31/2017 Senate Democrats of the Finance Committee boycotted the vote to advance the nomination of Congressman Tom Price (R-GA) for Secretary of Health and Human Services. Democrats cited misleading statements made by the nominee. They have previously argued that Price's financial investments---in particular his trading of medical stocks while he was in Congress---pose a conflict of interest. [97]
  • 1/27/2017 Secret recordings of closed-door discussions at a Republican retreat obtained by the Washington Post this week reveal that the party remains divided, uncertain, and deeply concerned about how to move forward with an Obamacare/ACA repeal.[98]
  • On 1/25/2017, a new survey from Penn was released, revealing that only 15% of primary care physicians support a repeal of the ACA. Even among Trump-voting physicians, that number is only 38%.[99]
  • On 1/25/2017, it was highlighted that during his hearing, Trump's pick for Health and Human Services Secretary, Rep. Tom Price, refused to promise that no Americans would be worse off under Trump's executive order easing provisions of the ACA, and said that one way of covering patients with preexisting conditions would be to push them into high-risk pools, which has limited coverage in the past[100].