The End of Obamacare -AND- Paul Ryan pledges ACA repeal, replacement in 2017; Democrats urge caution

CAL/AAEM News Service at
Mon Jan 23 23:49:09 PST 2017



January 5, 2017


The End of Obamacare



 <> The New
England Journal of Medicine



By Jonathan Oberlander, Ph.D.


Donald Trump's triumph in the 2016 presidential election marks the beginning
of an uncertain and tumultuous chapter in U.S. health policy. In the
election's aftermath, the immediate question is this: Can Republicans make
good on their pledge to repeal Obamacare? The Affordable Care Act (ACA) has
persisted largely thanks to President Barack Obama's protection. With Trump
in the White House and Republicans maintaining House and Senate majorities,
that protection is gone.


Obamacare's vulnerability reflects not only the 2016 election results, but
also its shallow political roots. The ACA has achieved much, including a
large reduction in the uninsured population. Still, it lacks strong public
support and an organized beneficiary lobby, has encountered significant
problems in its implementation, and has been enveloped by an environment of
hyperpartisanship.1 If the ACA were more popular and covered a more
politically sympathetic or influential population, if its insurance
exchanges were operating more successfully and had higher enrollment, and if
Democrats and Republicans were not so ideologically polarized and locked in
a power struggle, then an incoming GOP administration would probably be
talking about reforming rather than dismantling Obamacare.


The Trump administration can do much to undercut the ACA. The insurance
exchanges, buffeted in many states by high premium increases,
sicker-than-expected risk pools, and insurer withdrawals, require
stabilization; simply by doing nothing the GOP could damage them. A Trump
administration could also stop reimbursing insurers for the cost-sharing
reductions they must give low-income Americans with ACA exchange plans - a
move that would severely destabilize insurance marketplaces and lead to
insurers' exiting the exchanges.2 Just as the Obama administration used
executive orders to buttress the law, so the Trump administration could
reverse those orders and take additional actions to weaken it, including
leveraging waivers that enable states to opt out of ACA requirements.


The GOP-led House has already voted to repeal Obamacare dozens of times and
will most likely do so again. The situation in the Senate is more
complicated. The Republican majority of 51 senators is far less than the 60
votes necessary to overcome a filibuster and thereby pass contested
legislation. However, the GOP can use a legislative procedure that requires
only a simple majority - budget reconciliation - to overturn Obamacare's
main coverage provisions.


Republicans face challenges in dismantling the ACA. Procedural limits mean
that reconciliation can be used to repeal many Obamacare provisions but not
the entire law (its insurance market regulations would probably be spared).
Moreover, some of its provisions, such as banning insurers from
discriminating against people with preexisting conditions and allowing
children to stay on their parents' health plan until 26 years of age, are
popular. The GOP could attempt to retain such reforms, which President-elect
Trump has expressed interest in maintaining, while eliminating the mandates
for individuals to obtain and larger employers to offer insurance coverage
or pay penalties, the Cadillac tax on high-cost private plans, and other
measures the GOP opposes. Many ACA policies, though, are interconnected:
without a requirement that individuals either obtain insurance or pay a
penalty, regulations prohibiting insurers from excluding sicker people from
coverage or charging them higher premiums are not viable. Picking and
choosing to keep only the ACA's popular provisions is easier said than done.


Furthermore, more than 20 million Americans have gained insurance coverage
since the ACA's enactment, representing a sizable constituency of
beneficiaries of Medicaid expansion and subsidized marketplace insurance.
Repealing those benefits without adequate replacements would de-insure a
substantial share of the U.S. electorate, inviting a political firestorm.


Therein lies the GOP's chief quandary: talking about repealing the ACA is
much easier than actually repealing and replacing it. The GOP could
reintroduce a repeal bill, vetoed by Obama, that congressional Republicans
passed in 2015 (through budget reconciliation in the Senate) stripping the
ACA's core coverage provisions away.2,3 But with what, if anything, will the
GOP replace Obamacare? Trump's health care platform comprises a handful of
bullet points - including allowing the interstate sale of health insurance,
expanding the use of health savings accounts, and establishing high-risk
pools.4 None of those policies would do anything meaningful to restore the
access to health insurance that repealing the ACA would take away from
millions of Americans. Trump's reform vision remains largely a mystery.


Republicans could build on a June 2016 plan released by House GOP
leadership, led by Speaker Paul Ryan (WI). The plan shares the above
policies with Trump's platform.5 In addition, it calls for replacing the
ACA's insurance subsidies with tax credits. Insurers could not charge higher
premiums to people with preexisting conditions as long as, and only if,
those people maintained continuous coverage. The plan would limit the tax
exclusion for employer-sponsored insurance that has exempted employer
contributions to workers' insurance from taxation. And it would reform the
malpractice system by introducing caps on noneconomic damages.


Yet these policies, too, fall far short of the ACA's insurance protections
and coverage expansion. Under the House GOP plan, more Americans would be
uninsured, more would become underinsured, and more would be subject to
insurer discrimination. Nonetheless, even that proposal is viewed by some
conservatives as an overly ambitious "Obamacare lite."3 There is no
agreed-upon Republican replacement plan; a new health care reform debate
could expose divisions within the GOP and between Congress and Trump. If
Republicans want to replace the ACA, they must resolve issues such as how
ambitious a GOP reform package should be and how to pay for it. Limiting the
tax exclusion for employer insurance could generate considerable funds, but
many Americans will view that change as an unwelcome tax increase and a cut
in their health benefits.


Republicans' drive for repeal thus brings with it considerable political
risks. Americans are profoundly confused about the ACA's benefits, but the
prospect of losing them could prove clarifying. The 32 states, including
some governed by Republicans, that have expanded Medicaid do not want to
have coverage taken from their residents or to lose large federal payments.
Republicans may discover that it is harder to pull the plug on Medicaid
expansion than on the insurance exchanges. Other issues await the GOP, such
as what to do about the ACA's measures slowing down Medicare spending
growth. Ending those policies would substantially worsen the federal budget
deficit. And what becomes of the ACA's payment and delivery reforms, its
expansion of Medicare prescription-drug benefits, and myriad policies
affecting medical care and public health that are embedded in the law?


A host of health system stakeholders - hospitals, doctors, insurers, and
others - will be anxious about the current uncertainty in the health policy
landscape and worried about any changes that substantially reduce insurance
coverage and adversely affect their bottom lines. Much of the health care
industry supported the ACA as part of a broader coalition that included
consumer groups. Whether that coalition can reassemble to effectively resist
the ACA's demise is unclear.


Health policy debates could ignite beyond the ACA. Speaker Ryan supports
major changes to Medicare and Medicaid. The new Congress and the Trump
administration could enact large-scale tax cuts that reduce federal revenues
and increase the budget deficit, creating pressures to constrain spending on
government insurance programs. The 2015 House GOP plan called for
transforming Medicare into a modified voucher system, raising Medicare's age
of eligibility, and converting federal Medicaid payments to states into
block grants or per capita allotments. Pursuing those controversial
policies, which would shift more costs onto older and lower-income
Americans, could trigger a backlash. However, Trump may not support Ryan's
Medicare reform plans (though he has voiced support for block granting
Medicaid). The expiration of funding for the Children's Health Insurance
Program also looms in 2017.


The ACA's enactment represented a major step toward making health care a
right in the United States. Now after another landmark election, health care
reform in the United States is headed backward. It is uncertain which parts
of the ACA will survive past 2017 and what will follow it. What is certain
is that Obamacare as we know it will end.




January 6, 2017


Paul Ryan pledges ACA repeal, replacement in 2017; Democrats urge caution



Fierce Healthcare



By Leslie Small 


Republican leaders in Congress put up a unified front Thursday in support of
their plan to repeal and replace the Affordable Care Act, promising
replacement legislation will come this year. Democrats, meanwhile, continued
to fight for the law on several fronts.


"Our legislating will occur this year," House Speaker Paul Ryan said at his
weekly briefing, in response to a question about the timing of ACA repeal
and replacement legislation. He said the exact timeline, though, is still


Ryan also downplayed signs of dissent within the Republican ranks about
repealing the law before deciding on a replacement plan, saying: "we've been
planning for this for some time, and our members realize that." Republicans,
he said, are moving quickly to gut the law because it is rapidly failing and
they want to "stop the damage from getting worse."


"All the insurers tell us it's going to get even worse in 2017," he added.


The push to repeal large swaths of the law through budget reconciliation
scored another victory Thursday when the House Freedom Caucus said it would
support a budget measure that could swell the federal deficit to more than
$1 trillion by the end of the decade in the interest of an ACA repeal,
according to the Washington Post.


Senate Majority Leader Mitch McConnell also held firm in the GOP's
commitment to a quick repeal. "We're determined to live up to our promise to
the American people and repeal this failed law," then enact a replacement
that costs less and works better, he said Thursday. As for Democrats, he
said, "I hope they'll work with us."


Democrats push back


Sen. Tim Kaine, D-Va., called for a different form of collaboration, urged
his Republican colleagues to "sit down, and find solutions, and find
improvements and find reform" rather than rushing to repeal the ACA.


It is vital that Americans know what Republicans' plan is to replace the law
before repealing it, Sen. Cory Booker, D-N.J. added during debate on the
Senate floor. To Republicans, he said, "Do not thrust millions of your
countrymen and countrywomen off a cliff and shout promises at them as they


Kaine and his fellow Senate Democrats introduced an amendment Thursday that
would have required Republicans to get 60 votes on an ACA repeal measure
rather than a simple majority, but the Senate voted 52-48 along party lines
to reject the amendment.


Obama, Trump weigh in


Echoing his fellow Democrats and a rising chorus of healthcare industry
leaders, President Barack Obama warned against the dangers of repealing the
ACA before replacing it in an op-ed published by the New England Journal of


"This approach of 'repeal first and replace later' is, simply put,
irresponsible-and could slowly bleed the healthcare system that all of us
depend on," he wrote. Such a strategy is particularly risky, he argued,
since there might never be a second vote on a plan to replace the ACA.


"And if a second vote does not happen, tens of millions of Americans will be
harmed," he added.


President-elect Donald Trump, meanwhile, shared his views via Twitter,
lashing out on Thursday at Sen. Chuck Schumer, who has emerged as a strong
voice in opposition of Trump and congressional Republicans' agenda.


But on Friday, he offered a more conciliatory tone, calling for both parties
to work out a compromise on repealing and replacing the ACA.




Jeff Wells
Deputy Editor, CAL/AAEM News Service


Brian Potts MD, MBA
Managing Editor, CAL/AAEM News Service

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