Intended for healthcare professionals

Observations Yankee Doodling

As 2017 ends, Obamacare is still not safe

BMJ 2017; 359 doi: (Published 05 December 2017) Cite this as: BMJ 2017;359:j5630
  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}

Despite the Congressional repeal failures, coverage is threatened for many

When Donald Trump took office in January, the repeal of the Affordable Care Act (“Obamacare”) was one of his primary stated aims.1 So let’s review this year’s “progress.”

The House of Representatives wasted no time in trying to repeal the ACA. On 6 March House Republicans released a proposal to undo Obamacare, only to pull their bill two weeks later. They reintroduced another bill, however, and it passed on 4 May.2 That bill then sat for the rest of the year, waiting for the Senate to pass something similar.3

Senate Republicans introduced their own repeal bill on 22 June. For the bill to succeed in their closely divided body they invoked an arcane parliamentary process called “reconciliation,” which would allow them to pass the repeal with a simple majority. They couldn’t get enough support for this first bill, however, and they pulled it for redrafting.4

In late July Republicans introduced a scaled-back repeal bill, which seemed like it would pass, but on 28 July it failed by one vote. A final attempt to pass yet another version of the bill (the so called “Graham-Cassidy” bill) failed when leaders withdrew it after counting votes and realizing it would not pass either.5 The reconciliation vehicle expired, and no Senate bill emerged.3

Opponents of repeal, and presumably many of the millions of people who would have lost healthcare coverage under these various proposals, let out a sigh of relief. They figured that the ACA was safe now that Congress had moved onto other adventures, such as tax reform and trying to pass a budget for the federal government.

Not true.

Firstly, Trump has been actively trying to dismantle Obamacare by other means. He slashed funding for marketing and publicity for the ACA’s annual enrollment period. This seems not to have worked, as record numbers of patients are signing up. Also, he threatened—and now has actually withheld—government subsidies to help pay out-of-pocket premium costs for low income people.6 And he has expanded the available ACA health insurance products by introducing less comprehensive plans that will not provide what was previously defined as the minimum necessary coverage.

Secondly, while dithering over ACA repeal, Congress let a signal program that provides coverage for almost nine million children and 370 000 pregnant women expire. The Children’s Health Insurance Program lost its funding on 30 September, and states are beginning to notify patients that they will not be covered, starting this month.7

Tax reform

Finally, Congress is not quite done with Obamacare. One way that the Senate version of tax reform raises money to allow tax cuts is by repealing the “individual mandate” in the ACA. The mandate requires all Americans to have health insurance that meets certain standards, and many people receive federal subsidies to buy that coverage. It ensures that young healthy people also contribute to the health insurance funding pool, keeping rates lower for older, sicker patients. The impartial Congressional Budget Office estimates that if the individual mandate were repealed premiums would increase and 13 million to 15 million more people would be uninsured in 10 years’ time.89

Liberal commentators are outraged by this piecemeal destruction of the health insurance superstructure created largely by the ACA. Conservatives are delighted to wreck Obamacare in any way that they can. Whatever the commentariat thinks, millions of people seem to be headed for the uncertainty, financial distress, and adverse health effects that accompany lack of health insurance coverage. All without a formal repeal of the ACA. A truly sad time.



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