Congressional efforts to do away with Obamacare threatens leaving millions of Americans without any health insurance.
The American healthcare system is in danger. The Senate’s new Bill, the Better Care Reconciliation Act (BCRA), released in June, is an effort by the Republican Party to “repeal and replace” the Affordable Care Act (ACA), or ‘Obamacare,’ put forward by the Barack Obama administration. In doing so, it will shift the burden of cost to older, poorer Americans, threaten the provision of care for those with medical conditions, and make healthcare unaffordable for millions.
Obamacare had the most notable effect of providing 20 million Americans with health insurance. This was primarily done by expanding Medicaid eligibility, by protecting those with pre-existing conditions from being priced out or excluded from obtaining insurance, and by creating the virtual marketplace through which people could compare and choose plans that worked best for them aided by subsidies. Furthermore, it penalised individuals for not having health insurance through a fee imposed upon those who elected to remain uninsured, which helped ensure that financial risk was spread widely.
Both the BCRA and the House American Health Care Act (AHCA), a Bill that was passed by the lower chamber of the US Congress in May, deviate greatly from the ACA, unfortunately threatening the progress that has been made. The BCRA, drafted largely behind closed doors by Senate majority leader Mitch McConnell and a few Republican senators, was released over a week ago and will be up for a final vote after July 4. The BCRA has some differences from the previous Bill (now known as the AHCA), put forth by the Republican-controlled House of Representatives. While there are a number of differences among the ACA, the BCRA and the AHCA, some of the most notable have to do with the individual mandate, Medicaid expansion, tax subsidies and the pre-existing conditions clauses.
The individual mandate is an issue that tugs at a central debate among Democrats and Republicans, namely whether the government should be able to force an individual to buy health insurance. The irony is that other types of insurance, such as car insurance, are mandatory, yet insurance for one’s own health is constantly under question. In the US, anyone, regardless of having insurance or not, will be treated at an emergency department if they are medically unstable (put in place through EMTALA, a 1986 Act enacted by Congress). Thus, electing to not have insurance creates undue financial burden on hospitals and the health system (termed “uncompensated care”) because they end up footing the cost of the bill when an individual cannot afford to pay. Through the BCRA and AHCA Bills, the mandate would be replaced with less stringent measures that instead allow insurance companies to increase premium costs (the “premium” is a fixed amount that an individual pays for insurance each year).
Both the AHCA and BCRA are looking to phase out Medicaid expansion. Much of this debate has focused on the idea that “able-bodied adults” – namely those who are poor but are not disabled – should not be supported through entitlement programs such as Medicaid. Many Americans who are opposed to Medicaid expansion feel that providing support to this population discourages them from working. This is a frank misconception. Data from the Kaiser Family Foundation has shown that the majority of those who are newly covered through expansion are themselves working or members of a family in which a member is working. Furthermore, data has not shown that people who have been newly insured have reduced their participation in the workforce.
Under the ACA, Americans in financial need received health insurance subsidies when purchasing insurance in the marketplace based on their income, largely subsidised by taxes on the wealthy. Both the House and Senate Bills take different approaches to the health insurance subsidies. The House AHCA Bill bases both tax credits and subsidies on a person’s age, with older Americans receiving less. In the Senate Bill, subsidies would remain tied to income and geography, but also affected by age with older Americans also being hurt more. What’s alarming is that the major individual tax cuts that the Senate has proposed are for some of the wealthiest, namely those making more than $200,000 a year.
One of Obamacare’s most beloved and morally essential additions was the protection of Americans with pre-existing conditions. For decades, those who had medical conditions could be charged much higher premiums or rejected by insurance companies altogether. While the new Senate Bill does not allow for the rejection of those with pre-existing conditions, it does allow states to apply for a waiver that would let them redesign which “essential health benefits” that they will and will not cover. Currently, those include maternity care, mental health services, preventative and wellness services and more. As one might imagine, some of these may be the primary services that an individual needs.
Estimates from the Congressional Budget Office suggest that 22 million Americans could lose their health insurance if the Senate Bill is passed and signed by the president. This is unlikely at this point. Assuming all Democratic senators vote against the bill, only two Republican senators need to oppose it for it to not pass as is. Furthermore, if it does pass, it must then be reconciled with the House Bill before it is sent to the desk of the president for signing.
Abraar Karan is a physician at Brigham and Women’s Hospital and Harvard Medical School (Twitter @AbraarKaran). The opinions expressed in this article are solely those of the author and do not reflect the views and opinions of Brigham and Women’s Hospital.