I.
For those committed to the protection of vulnerable populations in the United States, perhaps the most reassuring part of a Hillary Rodham Clinton victory on November 8th would have been her administration’s ability to uphold and improve the Affordable Care Act (ACA). Despite Republican insistence that the central pillar of President Obama’s legacy is an utter failure, the ACA has made substantial gains that cannot be ignored or cast aside. For example, health insurance consumers are now guaranteed coverage at fair rates regardless of pre-existing conditions, gender, or overall health status. They are also protected from underinsurance due to annual or lifetime coverage limits. Perhaps most importantly, they are offered subsidies to pay for part of their premiums if they are unable to reasonably afford the full costs.
On the other hand, cost containment is an issue that the ACA has yet to solve; critics point to skyrocketing premiums on the exchanges as an indicator of the law’s defectiveness. Unfortunately, certain provisions that would have curbed the growth of premiums were blocked by lobbyists and Republicans as the bill was crafted. But these problems can be remedied under the current framework. In fact, many experts believe that a recommitment to this framework (with a few notable additions and changes) is the best course of action as our nation strives for high-quality, cost-effective coverage for every American.[3]
A President-elect Clinton would have led this effort of recommitment and readjustment; she planned to maintain the Affordable Care Act and add provisions to improve it. A measure that was ultimately forced out of the initial reform law but still has many supporters is a federally-operated health insurance plan, also known as the public option. This plan would have the ability to operate with low overhead and offer lower premiums than privately insured options. The resultant competition would drive down prices on all of the state health insurance exchanges, where consumers purchase insurance if not covered by an employer, Medicare, or Medicaid. This cost containment would be particularly striking for the states that currently have just one or two choices of insurers on their individual marketplaces and are therefore experiencing the biggest premium increases.[4] The establishment of the public option was one of Hillary Clinton’s central healthcare reform strategies, and even without significant Republican support for the provision, she might have been able to institute it.[5] In order to respond to the concerns of small business, she also supported a tax credit expansion for this important part of our economy. This measure would have helped employers pay for their employees’ premiums, which, in other words, would have protected both the financial interests of employers and the coverage status of employees.[6] Furthermore, Clinton favored increased financial assistance to individuals and families surrounding the poverty line (which would have encouraged continued growth in insurance coverage for those who need and deserve it most) and new financial assistance to privately insured individuals and families with burdensome out-of-pocket costs (which would have lent a hand to those who are finding it more and more difficult to keep up with the rising costs of care in this country).[7]
Of course, neither universal coverage nor total cost containment could have been immediately achieved by a new administration. For instance, it is unclear if Clinton would have been able to strengthen the individual mandate, which seems to be a necessary adjustment to the Affordable Care Act. The mandate, a central tenet of the law that requires all Americans to have some sort of health insurance coverage, is a crucial cost-containment mechanism but politically unpopular in conservative circles.[8] A much more progressive policy such as all-payer rate setting probably also would have been impossible in the near future; while the establishment of a finite range of prices for any given medical procedure is arguably the most effective way to bend the cost curve, a variety of lobbyist groups would be sure to fight tooth and nail against it.[9] In any case, the main point is that our nation’s healthcare reform effort needs leadership that is supportive of the ACA’s strengths, has the wisdom to understand that each part of the law is necessary for the success of the whole, has the patience to allow the market to stabilize, but is determined to promptly address the law’s gaps. Hillary Clinton’s hypothetical administration would have presumably met all four of those requirements. Donald J. Trump’s real and imminent administration seems to meet none.
With or without the support of the popular vote, Trump will be chosen by the electoral college to serve as the 45th President of the United States of America. Because he was the candidate of the Republican Party, the GOP congressional majority expects him to approve its legislation, and Democrats can do little to block these laws. Even in the case of a filibuster, the Senate only needs a simple majority to send any bill directly to President Trump’s desk that exclusively relates to spending.[[10] It just so happens that this type of bill, called a reconciliation bill, can easily address the loudest complaint of the Republican opposition for the past six years. A reconciliation bill, in other words, can effectively repeal the Affordable Care Act. In fact, the Restoring Americans’ Healthcare Freedom Reconciliation Act (H.R.3762) was a bill passed in January 2016 that, although vetoed by President Obama, would dismantle the reform effort upon its enactment.[11] The bill would abolish the individual mandate, remove the tax credits that helped low- and middle-income Americans pay for premiums, and erase the new Medicaid expansion. After the full transition of power this January, all Congress will have to do is pull this bill off the shelf and send it to the new president for his signature. With the stroke of a pen (one that will probably be branded with TRUMP and made in Mexico), 22 million Americans will lose access to health care, and the existing framework for future reform will be expunged from federal law.[12]
II.
Potential objections to this apocalyptic prediction must now be addressed. The most obvious is that Republicans claim not to pursue a simple repeal of the Affordable Care Act but instead a repeal-and-replace strategy that would, according to Trump in his post-election 60 Minutes interview, result in “great health care for much less money.” Trump also claimed that a replacement act would be passed “simultaneously” with the ACA repeal act: “It’ll be just fine…we’re not going to have a two-year period where there’s nothing.”[13] More importantly, this is the general consensus among the leaders of the Republican Party as well. Much like Trump, they say that the current reform law will be removed as soon as possible, that it will be replaced right away with something better, and that no one should worry too much about it.[14]
But even a cursory investigation of this narrative exposes its flaws and half-truths. House Republicans led by Speaker Paul Ryan did publish a healthcare policy paper entitled “A Better Way” in June 2016, which lays out the principles that undergird their healthcare reform intentions.[15] Trump can also reference the seven-point plan for healthcare reform on his website.[16] Regardless, neither of these documents serve as a concrete replacement bill. No legislation has been written by the House, no input has been offered by the Senate, and no economic impact assessment has been made by the Congressional Budget Office.[17] Republicans might say or even believe that they have a simple task ahead of them, but our legislative branch is far from sending a replacement bill to the president’s desk in any realistic sense. Furthermore, a replacement act needs to be passed in tandem with the repeal, whether or not this repeal includes a two-year transition period or “sunsetting” of the ACA (as H.R.3762 does). Our representatives cannot be so irresponsible as to nullify a law that supports the health of millions of Americans without painstakingly preparing a substitute and fully understanding its implications.
As an alternative response to fearful predictions about the future of healthcare reform, some Washington insiders have expressed their certitude that the GOP simply will not leave 22 million people without health insurance.[18] This thought is hopeful but baseless. Even if President Trump and the Republican-controlled Congress delay the ACA repeal until a replacement act is ready (which would mean enduring the daily insistence of their supporters), the specifics of their initial replacement plans place no focus on maintaining the present level of health insurance coverage. Ryan and Trump have floated ideas in the previously mentioned documents that include permission to sell insurance across state lines, block-grants to the states for Medicaid, reliance on Health Savings Accounts, and tax deductions of health insurance premiums. These ideas are all tangentially related to coverage, but none seem to even approach the comprehensive ways in which the Affordable Care Act subsidizes health insurance for low- and middle-income Americans.[19]
To this reality, some objectors might still resist. Even if they agree that the current replacement plan is inadequate in its fledgling state, they might remain certain that the GOP will somehow incorporate this large demographic of tenuously insured Americans by the end of the process. This perspective seems reasonable on the surface. Even apart from a moral assessment of the situation, a simple political assessment points out that Republicans would like to maintain their hold on the legislative branch in the 2018 midterm elections. Taking away the ability to pay for health insurance from 22 million voters is certainly not the best strategy to retain control. However, an ACA “sunsetting” period might help to minimally affect voting behavior. Also, a GOP distraction campaign is sure to follow any repeal-and-replace effort: not an abandonment of the poor (they will say), but a victory against low-quality, high-cost, socialized medicine. Apart from these efforts, it is important to recognize that our leaders simply do not suffer severe ramifications when they enact policy that harms low-income Americans. These are often the same Americans who are suppressed at the ballot box, who have no lobbyists to fight their battles, who have no voice. When left unchecked, these are some of the sociopolitical mechanisms that serve to maintain the status quo, and a Republican healthcare reform effort should not be expected to operate outside these norms.
To imply that people are overreacting to a potential repeal, casual observers might also point out that President-elect Trump has already begun to pivot from his absolute declarations that the Affordable Care Act is “a complete disaster.”[20] In fact, during the previously mentioned 60 Minutes interview, Trump insisted that certain popular provisions of the law will be maintained when the act is repealed. These observers might begin to wonder aloud if the final result of Republican healthcare reform will end up being “a barely changed version of Obamacare,” as John Oliver recently speculated.[21] But it is crucial to understand that the ACA does not function in a piecemeal fashion. It functions as a whole. If, as the president-elect suggests, he maintains protections for consumers with pre-existing conditions but nullifies community rating requirements, the individual mandate, and subsidies for the poor, he ensures that the people who most need health insurance cannot buy it—and raises premiums for everyone.[22] Perhaps Trump’s recent comments reveal his ignorance of the basic challenges that currently face healthcare reform, or perhaps they reveal his willful misdirection of the American people. In either case, Americans should not be thrilled, and they must not be tricked.
Speaking of the president-elect’s character and fitness for office, a final objection might be that the American people have no idea what Trump really believes or which bills he will ultimately sign into law. This is a fair point; perhaps the nation’s future leader will wake up someday soon with tickled heartstrings. Perhaps he will return to the words that he (or his ghostwriter) recorded in 2000:
“I’m a conservative on most issues but a liberal on health. It is an unacceptable but accurate fact that the number of uninsured Americans has risen to 42 million. Working out detailed plans will take time. But the goal should be clear: Our people are our greatest asset. We must take care of our own. We must have universal health care.”
Perhaps, in short, he will somehow find a way to avoid striking down his party’s most hated piece of legislation.[23] However, it is fairly concerning that the only thing that gives ACA defenders (quite little) solace is the same thing that makes Trump’s behavior seem autocratic.[24] His commitment to incoherence cannot be confused with that of any other double-speaking politician. His unstable temperament, unabated threats, and inability to denounce support from his most vile admirers cannot be confused with those of a simple grandstander. Americans should hardly feel comfort that they question the possibility of an ACA repeal only because they question their next president’s commitment to transparency and precedent.
III.
After analyzing these many objections and realizing that they do little to calm the fears of those who support the current healthcare reform effort, it becomes clear that the Affordable Care Act will most likely be repealed. The status of health insurance coverage for 22 million Americans will be placed in doubt, and many of these Americans will lose coverage when the dust settles. This threat to the collective health of our nation (and particularly to the health of the most vulnerable) is real, and it cannot be normalized or forgotten as we adjust to the realities of the incoming Trump administration. As must be the case for a number of important issues, we cannot fall silent or grow discouraged. We must publicly offer our support for the ACA. We must repeatedly reach out to our representatives. We must seek to change the minds of those around us.
Maybe if enough of us speak loudly enough for long enough, we can convince the Trump administration or the Republican-led Congress that the Affordable Care Act cannot in good conscience be repealed without the passage of a replacement act on the very same day. Maybe we can convince the framers of the replacement bill to include more support for low- and middle-income Americans than the “Better Way” policy paper and Trump’s barebones plan do. (And because a third Republican healthcare reform alternative called the Patient CARE Act exists that places a greater focus on this demographic, increased support might actually be a possibility.)[25] Maybe we can push this bill to the point where it maintains coverage for almost all of the Americans that had it under the ACA. Maybe we really can arrive at the “barely changed version of Obamacare” that John Oliver mentioned, just with a different name in order to appease the GOP base. Maybe we can even convince a few Republican congresspeople to oppose repeal altogether; maybe we can save the ACA and force Trump to look toward the sorts of reforms that Hillary Clinton supported.
However, most of that is unlikely. While it is vital that we recommit to political and community involvement in this time of profound uncertainty, we can only change so much at this point. Therefore, we cannot be surprised over the next few years by renewed increases in bankruptcy filings related to exorbitant hospital bills, poor health outcomes for vulnerable Americans, and excess death within these populations.[26] Without exaggeration, thousands of people’s lives will be ruined or ended early as a result of this policy shift.
I would hope that this fact horrifies any American, particularly those who voted for Trump and/or Republican congressional candidates. If it does, the important question becomes, “Why did you vote the way that you did?” I understand that voting involves a hopelessly complex decisionmaking process for many Americans and that it is impossible to represent all of your beliefs with one ballot. Furthermore, I find it useless and untrue to assert that every Trump voter is racist, misogynist, xenophobic, and unconcerned with the poor. On the other hand, I do believe that every Trump voter, purposefully or not, put a man and a party into power that have the ability to enact policy with those qualities. Therefore, an essential shortcoming possessed by some of these voters that we must continue to discuss is privilege. Because many of these voters are sheltered from the plight of certain demographic groups in this country, they have the privilege of refraining from interaction with the real concerns of these groups and altogether denying the reality of their experiences. Because they do not see any kind of real changes in their lives regardless of new administrations or policy shifts, they have the privilege of treating an election like a popularity contest or a sporting event instead of what it actually is: a choice between two completely different policy agendas, which will significantly impact the behavior of our government and the lives of many.
We have to pull certain Americans from this trance of negligence, tribalism, and inertia; we have to urge them to see that their fates are intimately tied to the fates of their fellow citizens (of the country and of the world). We have to continue to challenge these entrenched American notions that individualism results in the most desirable outcomes for all, or that government is inherently wasteful, inefficient, and untrustworthy. In the specific case of the Affordable Care Act and its fragile future, we have to call for a new American value: that access to health care is a fundamental human right.
Sources
[1] “Key Features of the Affordable Care Act By Year,” U.S. Department of Health & Human Services, August 13, 2015. https://www.hhs.gov/healthcare/facts-and-features/key-features-of-aca-by-year/index.html
[2] “20 million people have gained health insurance coverage because of the Affordable Care Act, new estimates show,” U.S. Department of Health & Human Services, March 3, 2016. http://www.hhs.gov/about/news/2016/03/03/20-million-people-have-gained-health-insurance-coverage-because-affordable-care-act-new-estimates
[3] Toussaint, John S, “Improve the Affordable Care Act, Don’t Repeal It,” Harvard Business Review, November 16, 2016. https://hbr.org/2016/11/improve-the-affordable-care-act-dont-repeal-it
[4] Hacker, Jacob S, “The Best Way to Save Obamacare,” New York Times, October 27, 2016. http://www.nytimes.com/2016/10/28/opinion/the-best-way-to-save-obamacare.html
[5] Greene, Jay, “Clinton voices support for public option health insurance plan,” Crain’s Detroit Business, August 11, 2016. http://www.crainsdetroit.com/article/20160811/BLOG010/160819963/clinton-voices-support-for-public-option-health-insurance-plan
[6] “Hillary Clinton Will Make Life Easier for Small Business at Every Step of the Way,” HillaryClinton.com, 2016.
https://www.hillaryclinton.com/briefing/factsheets/2016/08/23/hillary-clinton-will-make-life-easier-for-small-business-at-every-step-of-the-way/
[7] Eibner, Christine, Sarah Nowak, and Jodi Liu, “Hillary Clinton’s Health Care Reform Proposals: Anticipated Effects on Insurance Coverage, Out-of-Pocket Costs, and the Federal Deficit,” Commonwealth Fund, September 23, 2016. http://www.commonwealthfund.org/publications/issue-briefs/2016/sep/clinton-presidential-health-care-proposal
[8] “A Clinton White House Likely Would Try To Strengthen Individual Mandate Penalty,” Inside Health Policy, October 24, 2016.
https://insidehealthpolicy.com/daily-news/clinton-white-house-likely-would-try-strengthen-individual-mandate-penalty
[9] Kliff, Sarah, “All-payer rate setting: America’s back-door to single-payer?” Vox, February 9, 2015. http://www.vox.com/2015/2/9/8001173/all-payer-rate-setting
[10] Kliff, Sarah, “Trump and the GOP can absolutely repeal Obamacare — and 22 million people would lose health insurance,” Vox, November 9, 2016. http://www.vox.com/2016/11/9/13487772/trump-obamacare-repeal
[11] “H.R.3762 – To provide for reconciliation pursuant to section 2002 of the concurrent resolution on the budget for fiscal year 2016,” U.S. House of Representatives, October 16, 2015. https://www.congress.gov/bill/114th-congress/house-bill/3762
[12] Hall, Keith, “Re: Budgetary Effects of H.R. 3762, the Restoring Americans’ Healthcare Freedom Reconciliation Act, as Passed by the Senate on December 3, 2015,” Congressional Budget Office, December 11, 2015. https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/costestimate/hr3762senatepassed.pdf
[13] Stahl, Lesley, “President-elect Trump speaks to a divided country on 60 Minutes,” CBS News, November 13, 2016. http://www.cbsnews.com/news/60-minutes-donald-trump-family-melania-ivanka-lesley-stahl/
[14]Reilly, Katie, “Read Paul Ryan’s Speech Calling Donald Trump’s Victory the ‘Most Incredible Political Feat’,” Time, November 9, 2016. http://time.com/4564832/paul-ryan-speech-donald-trump-election/
[15] “A Better Way: Our Vision for a Confident America,” Office of the Speaker of the U.S. House of Representatives, June 22, 2016. https://abetterway.speaker.gov/_assets/pdf/ABetterWay-HealthCare-PolicyPaper.pdf
[16] “Healthcare Reform to Make America Great Again,” DonaldJTrump.com, 2016. https://www.donaldjtrump.com/positions/healthcare-reform
[17] Kliff, Sarah, “Trump and the GOP can absolutely repeal Obamacare — and 22 million people would lose health insurance,” Vox, November 9, 2016. http://www.vox.com/2016/11/9/13487772/trump-obamacare-repeal
[18] Kliff, Sarah, “Trump and the GOP can absolutely repeal Obamacare — and 22 million people would lose health insurance,” Vox, November 9, 2016. http://www.vox.com/2016/11/9/13487772/trump-obamacare-repeal
[19]Kliff, Sarah, “I read 7 Republican Obamacare replacement plans. Here’s what I learned,” Vox, November 17, 2016. http://www.vox.com/2016/11/17/13626438/obamacare-replacement-plans-comparison
[20] “Fox News/Facebook Two-Tier 2015 GOP primary debate,” On the Issues, August 6, 2015. http://www.ontheissues.org/2015_Fox_GOP.htm
[21] “President-Elect Trump: Last Week Tonight with John Oliver (HBO),” HBO, November 13, 2016. https://www.youtube.com/watch?v=-rSDUsMwakI
[22] Pearlstein, Steven, “Donald Trump is about to face a rude awakening over Obamacare,” Washington Post, November 12, 2016. https://www.washingtonpost.com/news/wonk/wp/2016/11/12/donald-trump-is-beginning-to-face-a-rude-awakening-over-obamacare/
[23] “Donald Trump in The America We Deserve,” On the Issues, July 2, 2000. http://www.ontheissues.org/Archive/America_We_Deserve_Donald_Trump.htm
[24] Gessen, Masha, “Autocracy: Rules for Survival,” New York Review of Books, November 10, 2016. http://www.nybooks.com/daily/2016/11/10/trump-election-autocracy-rules-for-survival/
[25] Burr, Hatch, Upton Unveil Obamacare Replacement Plan,” U.S. Senate Committee on Finance, February 5, 2015. http://www.finance.senate.gov/chairmans-news/burr-hatch-upton-unveil-obamacare-replacement-plan
[26] Wilper, Andrew P, Steffie Woolhandler, Karen E Lasser, Danny McCormick, David H Bor, and David U Himmelstein, “Health Insurance and Mortality in US Adults,” American Journal of Public Health, December, 2009. http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2008.157685
