Intended for healthcare professionals

Observations Yankee Doodling

There’s more to Obamacare than health insurance

BMJ 2017; 356 doi: (Published 20 January 2017) Cite this as: BMJ 2017;356:j338
  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}

Will public health, research, and quality improvement funding be repealed as well?

As Donald J Trump takes the oath of office to be the 45th US president, Congress has already begun the process of repealing the Affordable Care Act (“Obamacare”). Despite having a majority in both houses of Congress, Republicans cannot simply repeal the Act, because they don’t have the “super-majority” of the Senate that would be needed to cut off a Democratic filibuster. They can, however, by invoking an arcane and complex legislative process called “budget reconciliation,” limit debate on laws and pass them with their simple majority. This is the process they have just begun by passing budget resolutions in each house. The catch is that the ultimate repeal legislation can be used only to target certain types of spending and revenues. It won’t be as simple as repealing the entire law.

Most of the attention has understandably been on which spending related parts of the Act’s insurance provisions will be repealed. Prior efforts, for example, suggest that federal subsidies for purchasing health insurance, funding for Medicaid expansion, and the requirement that all eligible individuals buy health insurance are likely to go. Similar attention has been focused on what could possibly replace these provisions that would somehow meet Republican goals and not deprive millions of people of continuing health insurance.

Assuming that the Republican majority figures out a way to “repeal and replace” Obamacare, very little attention has been paid to the fate of the many parts of it unrelated to health insurance. Some of these involve government spending as well, and it is unclear whether they will be repealed along with the insurance portions of the law.

For example, Obamacare created a non-profit institute to support patient oriented comparative effectiveness research and funded it by establishing a billion dollar trust fund and a continuing tax on health insurance policies.1 Tens of millions of dollars have also gone to federal agencies to help disseminate the results of this research. Should all this be terminated?

Another provision of the law set up a federal prevention and public health fund to help prevent chronic diseases such as heart disease and diabetes.2 It currently funds state public health and prevention programs at $1bn (£0.8bn; €0.9bn) a year and is scheduled to increase this amount to $2bn by 2025. Will this be wiped out under budget reconciliation?

The law also created an innovation center within the Centers for Medicare and Medicaid Services to test strategies to improve healthcare quality while reducing costs.3 Its research and demonstration projects will have cost around $6bn by the end of the current fiscal year. Will this program be deleted?

Finally, to incentivize the delivery of evidence based clinical preventive services, Obamacare mandated that, unlike other healthcare, all such services are to be provided with no deductibles or copayments from patients. Will these regulations, which also have attendant costs, be withdrawn?

All of this is to say that, as important as it has been for increasing access to health insurance coverage, Obamacare has many other valuable provisions that are at risk of revocation. Congress should bear them in mind too while considering what they are in such a rush to repeal.



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