For years, Republican lawmakers have been pushing to repeal and replace Obamacare, and now that Donald Trump is in the White House, they’re working to make that finally happen.
But while the party seems to have little problem agreeing on repeal, they’ve had a much harder time agreeing on how to replace the law’s multitude of helpful provisions. Even seasoned wonks have a hard time envisioning what Republicans could offer to successfully replace the law.
We can’t say for sure that GOP lawmakers will succeed in their efforts to repeal Obamacare. They may be able to pass a reconciliation bill that only repeals spending-related provisions of the law, since that would need just 51 votes in the Senate. A replacement bill might include a provision to repeal the ACA in full, but it would also need 60 votes in the Senate to be filibuster proof. In short, the whole repeal/replace process if very uncertain right now.
Unfortunately, the average American doesn’t seem to have a good sense of what repeal could cost them. Many aren’t even certain that they’ve gained anything from the law. So to clarify, I’ve created a list of 50 things we’d lose if the ACA were to be fully repealed. (And I chose 50 just for starters — there are many more.)
If Republicans were to succeed in their efforts to fully repeal the ACA, here’s what they’d be taking away:
- The Affordable Care Act. In case you had any doubt, Obamacare is just another name for the Affordable Care Act (though more than a third of Americans don’t know that).
- The medical loss ratio. It’s the mandate that says health insurance companies have to spend the majority of their members’ premiums on medical costs.
- Coverage of pre-existing conditions. Before the ACA, people with pre-existing conditions found it expensive or impossible to get coverage in the individual market.
- … and freedom from waiting periods if you have a pre-existing condition. The ACA eliminated the waiting periods that employer-sponsored health plans used to impose before covering pre-existing conditions.
- Limits on waiting periods. If you get a new job and you’re eligible for your employer’s health plan, you might have to again wait more than 90 days before your coverage begins. The ACA limited waiting periods for newly eligible employees to no more than 90 days.
- Coverage that doesn’t have gaping holes. Employers could also go back to offering “mini-meds” and plans with huge holes in the coverage. Remember the movie John Q? Do you want the possibility that your employer might put you on a health plan that doesn’t cover organ transplants? Or that limits your total benefits to $10,000 a year? Or $2,000? The only reason large employers aren’t offering those plans anymore is because the ACA penalizes employers if the coverage they offer doesn’t meet minimum value standards. Without the ACA, those plans would return.
- Freedom from expensive COBRA coverage. People with pre-existing conditions who want to leave a job to become self-employed will likely find that COBRA coverage with budget-crushing premiums is once again their best option. (And COBRA isn’t available for all job-sponsored health plans).
- Escape from ‘job lock.’ In general, people will find themselves much more limited in their career options. Entrepreneurial paths will be unavailable to many, because the well-regulated individual market will revert to the “Wild West” system that existed pre-ACA.
- Benefits for coal miners and their survivors. Miners disabled by black lung disease, and their survivors, are eligible for federal benefits as a result of Section 1556 of the ACA, but could lose them under repeal.
- Freedom from lifetime limits. Lifetime benefit limits will come back. If you or a loved one has hemophilia or a very premature baby, for example, you could use up all of your health insurance benefits very quickly, and have nowhere else to turn.
- Escape from annual benefit limits, which are similar to lifetime limits, only smaller.
- A level playing field for women. It’s likely that women will again charged more for coverage than men – like they were in the “good old days” – despite the fact that individual market coverage will revert to not covering maternity care.
- FREE colonoscopies. A colonoscopy can cost more than $2,000 if you have to pay for it yourself.
- FREE routine cholesterol and blood pressure checks will no longer be free.
- Escape from the Medicare Part D “donut hole.” The donut hole will be back with a vengeance. Before the ACA, Medicare enrollees had to pay the full cost of their medications while they were in the donut hole. In 2017, while in the donut hole, seniors pay just 40 percent of the cost of brand-name drugs, and 51 percent of the cost of generic drugs. Without the ACA, they’ll be back to paying 100 percent.
- Decreased Medicare spending. With repeal, Medicare spending is projected to increase by $802 billion over the next decade. The result will be higher premiums, copays, deductibles and coinsurance for Medicare beneficiaries. Medicare premiums increased this year, but the impact would be even more significant in future years, if the ACA is repealed.
- The option to disenroll from Medicare Advantage and sign up for Part D at the start of each year. Medicare Advantage enrollees have been better protected as a result of ACA Section 3204, which provides an annual Medicare Advantage disenrollment period from January 1 to February 14. Prior to the implementation of Section 3204 in 2011, Medicare Advantage enrollees had an open enrollment period during which they could make changes to their plan, but they couldn’t add Part D coverage if they didn’t already have it, and they couldn’t drop it if they did have it. The Medicare Advantage disenrollment period lets seniors drop their Medicare Advantage plan, switch back to Original Medicare, and purchase a Part D plan.
- Medicare’s annual wellness visit for all beneficiaries. It’s available now as a result of the ACA, but would disappear if the ACA were repealed.
- Insurance options for immigrant over age 64. Do you have elderly parents living overseas, who would like to move to the U.S.? If the ACA is repealed, they’ll have little in the way of health insurance options for the first five years after they move here. They can’t buy into Medicare during that time, and would be declined by individual market health plans if pre-ACA rules are resurrected. (Individual market plans used to reject enrollments from people over the age of 64, even if they weren’t eligible for Medicare.)
- Prescription drug coverage. Some health plans will be sold without prescription drug coverage, or with coverage for only generic drugs. It might sound fine – until you actually get sick and need prescriptions. For example, there aren’t any MS drugs that cost less than $50,000/year, which is a bit of a stretch if your health plan doesn’t cover medications.
- Maternity care. Most health plans in the individual market won’t cover maternity care. In many states, you won’t have any options for plans with maternity coverage if you don’t have access to an employer-sponsored plan.
- FREE birth control. Free contraception will disappear. IUDs will go back to costing $500 to $1,000 up front, and female sterilization will set you back up to $6,000. (Both are covered in full under Obamacare).
- Protection from discrimination. LGBT Americans will likely lose access to coverage and necessary medical treatment. Section 1557 of the ACA prohibits discrimination in health plans, including discrimination based on gender identity or sexual orientation. That has been a boon to the LGBT community, but without the ACA’s protections, many would find their access to health care in jeopardy once again.
- FREE routine vaccinations. You’ll have to start paying for them again – including fees for the office visit and the vaccine itself.
- FREE breastfeeding supplies. New moms will no longer have access to free breastfeeding supplies (such as a pump) and the support they need to successfully breastfeed.
- Privacy if you’re breastfeeding. Nursing mothers might no longer have realistic access to pumping milk while at work. ACA Section 4207 requires large employers to provide nursing mothers with a private space (not a bathroom) in which they can pump, and adequate time to do so during the work day. If you know a nursing mother, she’s grateful for this provision.
- FREE screening for gestational diabetes will disappear, and pregnant women will have to pay for the screening (along with the full cost of their maternity care if they have coverage in the individual market).
- FREE pap smears and HPV tests. Obamacare requires insurers to provide free pap smears and HPV tests, but if the law is repealed, expect to start paying for those again, including office visit copays and lab charges.
- FREE screenings for HIV, Gonorrhea, and Hepatitis. These screenings are part of the ACA’s preventive care requirements.
- FREE tobacco cessation. Under Obamacare, health insurance plans provide cessation assistance. If the law is repealed, you’ll pay for that again too.
- FREE Rh incompatibility screening. The ACA requires free Rh incompatibility screening for pregnant women, which can be lifesaving for the baby.
- Medicaid coverage for low-income Americans. Millions who’ve relied on Medicaid since 2014 could find themselves uninsured again. Obamacare expanded Medicaid, but the Supreme Court made it optional for states. As of 2017, Medicaid has been expanded in 31 states and DC, and 12.3 million people had gained coverage as a result, by late 2016. Louisiana expanded Medicaid in 2016, and has been maintaining a website that shows the number of people who have obtained preventive care and potentially life-saving treatment as a result. It’s eye-opening, especially when you consider the same impact in 30 other states, most of which expanded Medicaid more than two years before Louisiana.
- Improved mortality rates for people with HIV. Under Obamacare, people with HIV are less likely to die since ACA-compliant coverage is guaranteed-issue and the majority of the states have expanded Medicaid. Repealing the ACA would reverse the declining trend in mortality rates.
- Substance abuse treatment. Without the ACA, individual and small-group plans will no longer be required to cover substance abuse treatment. Millions of people on Medicaid will also lose their coverage that includes benefits for substance abuse treatment. That’s not likely to help combat the current opioid crisis.
- Your hospital? It could happen. Some hospitals – particularly in rural areas – will close, particularly in the states that accepted the ACA’s Medicaid expansion – and thus significantly decreased their uninsured rates since 2013. If low-income populations in those states revert to being uninsured, hospitals will still have to treat them in emergency situations, but will receive little or no compensation for doing so.
- A record-low uninsurance rate. After decreasing steadily since 2013, the percentage of uninsured Americans will spike upwards. The Congressional Budget Office estimates that by 2026, the number of uninsured Americans would increase by 32 million if H.R.3762 (last year’s reconciliation bill to repeal the ACA) were implemented.
- Premium subsidies. Middle-class Americans who buy their own health insurance will lose the subsidies (tax credits) that currently pay a portion of their premiums. ACA replacement proposals generally call for some sort of tax credit, but they’ll likely be smaller and less helpful for people who need them the most.
- Coverage on your plan for your adult children. Young adults will no longer be able to stay on their parents’ health insurance plans until age 26.
- Improved plans for college students. Thanks to the ACA, the health plans offered to college students today are just as good as the plans offered to everyone else. If it’s repealed, health plans offered to college students will revert to limited-benefit coverage with low annual benefit maximums.
- Ease of claim appeals. Under Obamacare, there’s an internal appeals process, and if that doesn’t work, you have the right to an external review by an independent organization. Those protections would disappear if Obamacare is repealed.
- Protection from rescission. Under the ACA, recission (retroactive cancellation of your coverage) by your health insurance carrier is prohibited – unless your application was fraudulent or included intentional misrepresentation. Back in the pre-ACA days, in most states, individual health insurance applications included numerous questions about the applicant’s medical history. If an applicant forgot to mention a condition, and then later developed a completely unrelated medical condition, the carrier could rescind the policy based on the application error. The rules about rescission are more stringent under Obamacare, but more to the point, health insurance applications no longer ask about medical history (other than tobacco use), which eliminates much of the misrepresentation problems that used to occur.
- Easier to understand benefit descriptions. The ACA requires health insurers to provide coverage explanations in easy-to-understand, standardized formats, along with uniform definitions of health insurance terminology. Without the ACA, that standardization and simplification would no longer be required.
- Effective rate review. Before the ACA was implemented, some states went to great lengths to ensure that premiums were actuarially justified, but others did very little. Combined with the fact that there were no federal medical loss ratio requirements in place before the ACA, residents in some states were getting fleeced by some health insurers. The ACA implemented a system that requires an actuarial review of any proposed rate increase of 10 percent or more, and details are published so consumers can see them. If the ACA’s repealed, rate reviews would become essentially meaningless in some states.
- Cost-sharing subsidies that lower out-of-pocket costs. Republicans pushing for repeal would love to axe cost-sharing subsidies – these subsidies paid directly to insurance companies that allow lower-income enrollees to have much lower out-of-pocket costs than they would otherwise have (House Republicans have been challenging cost-sharing subsidies in court since 2014). If you earn $20,000 a year and you’ve got a health plan through the exchange that has no deductible, you’re benefitting from the ACA’s cost-sharing subsidies. Without them, health care would become much less affordable.
- Low-cost health insurance in New York and Minnesota. If you’re in New York or Minnesota and you earn too much for Medicaid eligibility, but not more than 200 percent of the poverty level, you’re currently eligible for Basic Health Program coverage. In New York, it’s called the Essential Plan, and in Minnesota, it’s called MinnesotaCare. These programs were established under Section 1331 of the ACA – and will be eliminated if the ACA is fully repealed.
- Caps on your out-of-pocket costs. Under the ACA, health plans have to cap enrollees’ out-of-pocket exposure for in-network care. In 2017, the upper limit is $7,150 for an individual, and $14,300 for a family (many plans have limits well below that, but that’s the maximum). And the individual limit is required to be embedded in family plans. Without the ACA, we’d see a return of plans that have out-of-pocket limits of $20,000 or more. Those plans were particularly problematic when they were marketed to lower-income people, especially if the out-of-pocket exposure wasn’t well explained in the marketing materials and presentation.
- More affordable coverage if you work for a small business. Do you work for a small business that’s providing you with health insurance? Your employer might be getting an ACA-created tax credit to make offering coverage more affordable. If the ACA goes, small-business tax credits for health insurance premiums would disappear, too.
- Health plan options for employees of small businesses. If you work for a small employer who has coverage through the small business exchange, it’s the exchange that’s allowing you to select from among a variety of health plans. Without the ACA, those choices are likely to vanish.
- Lower prescription costs. Low-income seniors and disabled Americans could see increased prescription costs. Section 3309 of the ACA eliminated out-of-pocket drug costs for people who are covered by both Medicare and Medicaid, if they are receiving home-based care that allows them to avoid having to move into a nursing home. People who are dual eligible for Medicare and Medicaid are among our most vulnerable populations.
- Pediatric dental insurance. Do your kids have dental insurance now? Pediatric dental coverage is one of the ACA’s essential health benefits, and the percentage of children with dental coverage is at an all-time high.
Did any of these benefits catch you by surprise? If so, you’re not alone. It’s common for people to think that Obamacare only encompasses the health insurance exchanges, or that its provisions only apply to a small segment of the American population. In reality, that couldn’t be further from the truth.
If you’re concerned about what you or your loved ones might lose if the ACA is repealed, speak up. Reach out to your elected officials and let them know your concerns.
It’s true that the ACA has flaws, and could use some fine-tuning. But repealing it would eliminate a multitude of positive changes that have been implemented over the last several years.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.