Obamacare is Dead. Long Live Obamacare!

Obamacare has had more near-death experiences than any public policy proposal in memory.

The Patient Protection and Affordable Care Act’s passage resembled the “Perils of Pauline” more than “How a Bill Becomes a Law,” with at least three times that nearly every one of President Barack Obama’s advisers suggested abandoning the effort–and him deciding instead to double down and somehow successfully got it through, as documented by Jonathan Cohn in the New Republic. This included going forward with health reform alongside the stimulus and other efforts to address the economic freefall he inherited; the response to the “Tea Party” protests in the 2009 summer recess, where instead of moving on he rallied with a major address to Congress; and finally after the election of Scott Brown to fill Ted Kennedy’s seat, requiring the House to basically accept the Senate version of the bill, with changes to follow after.

But even after passage, the law’s roller coaster continued, with a proverbial nine lives, as described by Richard Kirsch at the Roosevelt Institute (formerly campaign manager for Health Care for America Now). These momentous moments included two major Supreme Court decisions, over 60 Congressional votes to repeal the law and a government shutdown, the failure of Healthcare.gov, and several elections afterwards–one that re-elected Obama to ensure implementation would continue and coverage would be extended, but others that gave Congress, and eventually the Presidency to the Obamacare’s opponents.

This last election looked like the law’s luck had finally run out–while 3 million more Americans voted for the candidate who wanted to build on the success of the ACA, the new President and the new Congress had in fact run on repeal, and they had levers of power in hand to do it.

But–in the very same breath they promised repeal, they also promised to replace, with something better. At any given statement by the President or members of Congress, that meant covering more people or less cost-sharing and deductibles or just something “terrific”–which sounded great but was wholly antithetical to the policies they actually supported, which uniformly would encourage higher deductible and cost-sharing and skimpier plans–if not just a withdrawal of the federal role of facilitating coverage to begin with, and many more uninsured as a result. There’s an argument to make (that we disagree with) about shifting costs onto consumers, or why it’s not the role of government to help people get coverage–but they didn’t make it. So when they finally introduced their plan, the American Health Care Act, it failed to match their own rhetoric in terms of improving coverage, nor their own policy goals or vision either.

Beyond the specific policy elements or the people covered, it’s an accomplishment of the ACA that now even the opponent’s health plans are judged by the notion of whether more or less Americans have coverage. Yet it’s still disturbing that Speaker Paul Ryan said that the vote count on the American Health Care Act was “very close,” when it should have been dead once the Congressional Budget Office analysis showed 24 million more Americans would have been uninsured under the plan. While 38 California Representatives were opposed from the outset, it was disturbing that the 14 Congressmembers from California–the state with the most to lose, since we gained the most–did not at anytime publicly oppose the bill. Some supported, and others held their opinions close–even while privately sharing their concerns. They missed their moment for leadership, to show courage on behalf of the care and coverage for their own constituents.

Maybe those members were hiding behind the fiction that AHCA was a “repeal and replace of Obamacare,” when it was both much less and much more than that. It was aggravating to hear so many in the media repeat the claim, unqualified, that the AHCA was the GOP plan to “repeal and replace” Obamacare. If every analysis shows that AHCA would leave most (if not all, if not more) of the newly covered uninsured, then it’s not much of a replacement–and shouldn’t have been described as such.

Such a description also shortchanged the far-reaching impacts of the AHCA, which was a radical restructuring of our health system, much more than the ACA did. The demise of AHCA also meant the demise of (at least for now):

  • a cap on the Medicaid program, undoing a 50-year guarantee between the federal and state government, and cut to the program by $880 billion dollars;
  • the undoing of key consumer protections to keep coverage meaningful, including minimum value standards, essential health benefits, and annual and lifetime limits on cost sharing
  • the defunding of Planned Parenthood and restricting Medicaid beneficiaries from using these key providers for covered preventive services
  • a tax hike for low- and moderate-income purchasers of individual health coverage, who would see their average tax credit be cut in half within a decade
  • a massive tax giveaway to the wealthiest, to investors, and to the health industry including drug and insurance companies–including a tax break for health plan executives making over $500,000
  • revenue reductions that cut years off the lifespan of the Medicare trust fund–potentially setting up another effort to voucherize Medicare
  • a 12% cut to the CDC and other funds for public health and prevention
  • the changing of a budget baseline to make it easier to pass a regressive tax reform measure this summer

…and much more. This was much more than a Obamacare repeal bill–and certainly no replacement.

With the death of AHCA should also be the death of Obamacare as a term. President Obama is no longer in office; President Trump is in charge, and has be responsible for its implementation going forward. With regulatory actions and executive orders, he has already moved in a very different direction than his predecessor. It is as much Trumpcare as it is Obamacare. He and his HHS Secretary Tom Price have limited but real authority to make changes to regulations implemented the various elements of the law, and even to potentially undo funding for cost-sharing. Will they really, with their actions, make cost-sharing and deductibles more expensive for consumers by taking away cost-sharing subsidies worth $900 million/year just in California? We will see.

If “Obamacare” was ever an appropriate title for the media to use (it wasn’t), it is less so now. The term Obamacare always obscured more than it enlightened. The ACA actually left a lot of the health system intact, for better (to minimize disruption) and for worse (some existing problems continued)–but the term Obamacare suggested that every problem was a result of the law, when in fact the law provided tools for consumers to deal with longstanding issues like rising premiums: tax credits tied to premiums so lower- and moderate-income families can better afford coverage, the ability to shop around without being locked into a plan, etc. References to “Obamacare” often never clarified which component they were talking about, most notably the expansion of Medicaid, or the availability of affordability assistance through marketplaces like healthcare.gov or Covered California.

Hopefully, media reports will now dispense with the “Obamacare” moniker and to focus on these components going forward: Medicaid, the marketplace tax credits, etc. Obamacare is dead, because it really is interwoven into the existing health care system. The failure of AHCA means that the ACA is now solidified into the health care landscape–the new platform that we can build on an take additional steps toward an improved health care system.

In California, we had already been working to implement and improve on the Affordable Care Act, moving past the Obamacare debate to the specific solutions on everything from surprise medical bills to inaccurate provider directories to timely access to care to rising prescription drug prices, to broader efforts to expand coverage and address health care costs, and ultimately get to the goal of quality, affordable health care for all Californians. Hopefully the nation will join us in that journey.