Intended for healthcare professionals

Observations Yankee Doodling

What now for Obamacare?

BMJ 2016; 355 doi: (Published 10 November 2016) Cite this as: BMJ 2016;355:i6063
  1. Douglas Kamerow, senior scholar, Robert Graham Center for policy studies in primary care, professor of family medicine at Georgetown University, and associate editor, The BMJ
  1. dkamerow{at}

Trump and Congress promise to repeal it, which may not be easy

This is not the column I was originally going to write.

Days ago, way back when Hillary Clinton was likely to become president, I was planning a post-election piece on her options to improve the Affordable Care Act (“Obamacare”). This, of course, is not on President elect Donald J Trump’s agenda.1

With Trump headed for the White House and Republicans still in control of both houses of Congress, we are told that Obamacare’s demise is just a matter of time.23 Recent concerns about how to fix the law to deal with serious problems such as rising costs to patients and decreasing choice of coverage plans now seem like minor issues in the face of a threat to the law’s entire existence.

During the closing days of the campaign, Trump repeatedly called for the repeal of Obamacare, saying at one point that he might call Congress into “special session” to do so.4 (This despite the fact that by the time he is inaugurated, 20 January, Congress will already be in session.) However, any legislation that flatly repeals a law would be subject to filibuster in the Senate by Democrats, who still have enough votes there to block such a bill.

In addition, many provisions of Obamacare have been very popular, even with Republicans. It forbids denial of coverage because of pre-existing medical conditions. It mandates free provision of evidence based preventive services. It removed lifetime caps on coverage of expensive care. It prescribed a uniform essential benefits package. And so on.

Further, the law has dramatically increased healthcare coverage, with 20 million more Americans now having some sort of insurance than in 2010.5 Many of them get free care through expansions of Medicaid. Others get subsidies to help them afford the premiums for their policies. It is not clear how you take away benefits such as these once they are available and being used by millions of people.

Still, there are plenty of ways in which the law can be weakened, if not repealed. Barack Obama has aggressively supported the act with unilateral administrative rulings that have extended its reach and powers. These could be rescinded by a President Trump. Congress, for its part, has ways of passing carefully constructed legislation through the so called “reconciliation” pathway that cannot be filibustered and requires only a simple majority (which the Republicans have) to pass. This is a bit tricky, and it would stop short of outright repeal, but it could seriously wound the law and invalidate many of its provisions.

Democrats and their supporters won’t be sitting still while all this goes on, of course. They are already convening allies to lobby against any changes to Obamacare.2 Some think that dismantling the health law is actually not very high on Trump’s agenda and thus will not be a battle for the first part of his term.3 And it has survived an unprecedented number of assaults already, including two Supreme Court challenges and numerous attempts at repeal.

So it is not time to count Obamacare out. But it certainly looks threatened.



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