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National Health Care is an important issue right now. With the president elect Trump repeal of the Affordable Care Act. The ethics behind it are poor. With the removal of ACA would leave hospitals, and many people that are insured on it left with little to nothing. Trump plan is to not take away all of the act but to replace some parts. The people on the act would get screwed because they need it to survive and live a normal life. Leaving the millions of low income families without health insurance.

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Acceptance Speech & Fear of Donald Trump

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The Daily Show - Between the Scenes - Obamacare vs. the Affordable Care Act

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Trevor gives props to whatever political mastermind started calling the Affordable Care Act "Obamacare." Watch full episodes of The Daily Show now -- no login required: http://www.cc.com/shows/the-daily-show-with-trevor-noah/full-episodes The Daily Show with Trevor Noah airs weeknights at 11/10c on Comedy Central.

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Everyone

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pictures related to the repeal of the ACA

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pictures related to the repeal of the ACA

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Last Wednesday marked the sixth anniversary of the passage of the Patient Protection and Affordable Care Act. As of this week, the five Presidential aspirants have each articulated key changes they'd propose, though polls show interest in the law is largely among Democrats who consider healthcare a major issue along with national security and the economy.

GOP candidates Trump, Cruz and Kasich say they will repeal the law; Democratic frontrunner Clinton says she will repair it, and her challenger, Bernie Sanders, promises to replace it with universal coverage. Some speculate that candidate Clinton's plan will ultimately mirror her Health Security Act of 1993 that parallels the Affordable Care Act in many respects. But the law gets scant attention on the campaign trails other than their intent about its destiny if elected.

I have read the ACA at least 30 times, each time musing over its complexity, intended results, unintended consequences and hanging chads. At the risk of over-simplification, the law purposed to achieve two aims: to increase access to insurance for those unable to qualify or afford coverage, and to bend the cost curve downward from its 30 year climb. It passed both houses of Congress in the midst of our nation's second deepest downturn since the Great Depression. Unemployment was above 10%, the GDP was flat, and companies were cutting costs and offshoring to adapt.

The "Patient Protection and Affordable Care Act" soon after became known as the "Affordable Care Act", and then, in the 2010 Congressional Campaign season that followed its passage, "Obamacare". It was then and now a divisive law: Kaiser tracking polls show the nation has been evenly divided for and against: those opposed see it as "the government takeover of healthcare" that will dismantle an arguably expensive system that works for most, while those supportive see it as a necessary to securing insurance coverage for those lacking.

In the Congressional campaigns of 2010, proponents of the Affordable Care Act took a beating: control of Congress shifted from Dem's to the GOP and from that day forward, what followed in the GOP controlled House of Representatives were 52 votes to repeal it including last week's 228-199 vote on HR37 included in the GOP FY2017 budget. The Senate lacked the muster to follow suit but the House persisted.

The PPACA was to be implemented for the period of 2010-2019. It was the Senate version that ultimately passed the House, with the drama focused on late vote-getting by Democratic leadership who concluded the Senate's less aggressive, more state-friendly law was the only hope for health reform legislation. It is premised on simple assumptions:

Covering those without insurance is preferable to letting their ranks swell. At the time of passage, the uninsured rate in the US was 16% and trending upward. Today, it's 9%. Theoretically, offering insurance to lower income qualified citizens through either Medicaid expansion or the insurance exchanges would serve two purposes: lower costs for their care by pre-empting expensive emergency room visits, and lower costs for everyone else through lower insurance premiums, lower hospital costs because bad debt would be lower and so on.

Quality of care can be measured and its relationship to volume made known to purchasers. The law builds on reputable work by RAND, IHI, Dartmouth and others showing more care is not better care, and process improvements in diagnosing and treating conditions results in better outcomes and lower inappropriate variation. Further, it presumes that quality can be measured and its correlation to costs made known to purchasers who can decide for themselves if more is better. Throughout the law's myriad of programs, demonstration and pilots, quality measures are embedded: most are process measures and a few are actual patient outcomes.

Provider organizations will compete on the basis of value. The law places the burden of financing (insurance) and the delivery of care on doctors and hospitals because they're trusted. By doubling down on transparency and tightening the screws on self-referrals and business practices that benefit producers over consumers, the law presumes the system will adapt to competition based on a provider organization's performance around its costs, outcomes, error, user experiences and service delivery. Thus, by changing the incentives for providers from volume to value, a competitive private market will result.

States must play a key role in implementing health reforms. Finally, the crafting of the law drew on the reality that health reform circa New York State is a decidedly different path than Arkansas or Iowa. That was the vigorous debate in the Senate's Finance Committee where the law was crafted. Thus, defining essential health benefits, credentialing providers around scope of practice, the option of state-run health insurance exchanges et al were left to the devices of state legislatures and the state's Chief Executives. The Supreme Court's ruling June 28, 2012 that affirmed the constitutionality of the law reinforced the state role by negating the law's mandate that Medicaid be expanded in every state.

Of 88 provisions in the law, 82 have been or are on target to be implemented (Kaiser Family Foundation). HHS' touts the law as a huge success: 12.7 million have gained coverage through the health exchange marketplaces (83% of these are counting on tax credits averaging $290/month to help them pay their premiums), 2.3 million young invincibles gained coverage by staying on their parent's plans and Medicaid expansion in 32 states plus DC added 6 million. In almost every community, physicians and hospitals are participating in some form of shared risk with Medicare via accountable care organizations or bundled payment programs, and the Congressional Budget Office predicts the law will cost $465 billion to implement between now and 2019, which is 25% lower than it estimated when passed in 2010.

Others call attention to the law's unintended consequences: massive consolidation of the industry in every sector, disruption of physician-patient relationships as narrow networks gained traction, higher insurance premiums due to the law's restrictions, added costs for drugs and devices as a result of the law's new excise taxes, and a general sense of frustration by the industry's frontline workers accustomed to operating on axioms like 'all healthcare is local" and "doing less means poor quality".

Retrospectively, what have we learned?

The law has fundamentally changed the structure of the healthcare industry across the board. Private insurers adapted quickly: premium increases and plan design changes were almost immediate. Providers-hospitals and doctors especially, adapted slowly, since the risks are unclear and the disruption costly. Drug and device manufacturers focused their R&D on surer bets and raised prices, and healthcare investors took advantage of the changes to drive efficiency and innovation through consolidation. Today, more than one in three physicians is employed in a hospital; Anthem's acquiring Cigna and Aetna's acquiring Humana, and United Health Group is repositioning itself as Optum, the innovation company. Go big or get out is new the rule of the realm.

No one knows for sure how much the ACA will cost or how many will receiver coverage. Keeping up with forecasts of the law's cost and coverage impacts from the CMS Office of the Actuary and the Congressional Budget Office is virtually impossible. When passed, the estimates were increased coverage for 52 million by 2019 through the cumulative impact of Medicaid and CHIP expansion, employer and individual mandates, tax credits for small businesses to provide employee coverage, and tax credits to individuals with incomes between 100-400% of the federal poverty level to purchase coverage. In the latest CBO forecast, the costs of the ACA are lower than projected, but that's largely due to lower-than-expected enrollment in the new programs and the Supreme Court ruling June 28, 2012 that states could not be forced to expand their Medicaid programs.

The PR campaign for the law was ineffective. Calling the law Obamacare hurt public support. What would have happened if Lyndon Johnson's great society had been coined as "Johnsoncare". It would have died a slow, painful death. "Medicare" made sense. Perhaps the creative genius behind "Grande" and "Latte" at Starbucks should have been tapped to craft the law's PR campaign. The law's supporters failed to harness the public's support for many of the law's provisions that were wildly popular-cessation of pre-existing conditions for insurance coverage, expansion of coverage to eligible adults under 26 who could stay on a parent's plan, elimination of annual and lifetime limits on coverage, elimination of the prescription drug donut hole obligation for seniors and many others features. But the law's proponents failed to galvanize a public mandate to reform the system and wilted against counter-attacks from its opposition in the toxic climate of partisan politics.

The law is complicated. Might a more prudent strategy have been to tackle insurance industry reforms first, and delivery system changes later? We'll never know for sure.

So the Campaign 2016 question is this: what's the likelihood the Affordable Care Act will be repealed? It's highly doubtful for three reasons:

First, the composition of Congress required to support its repeal isn't likely to override a Presidential veto, assuming a Democrat is in the White House next year. It takes a two-thirds majority in both Houses to override a Presidential veto. If a Republican is in the Oval Office next year, it would likely still require 60 GOP votes in the Senate to advance its repeal bill-a prospect that's suspect since 24 of the 34 seats up for election in this cycle belong to Republicans who currently hold 54 seats in the upper chamber.

Second, the undoing of the law's expansion of coverage is problematic. Granted, the extension of Medicaid could default to the states, and the federal government is on the hook for the tax credits, but the myriad of provisions in the law that enable individuals and small businesses to access coverage with tax credits seems intractable in the near term.

And third, replacing the ACA sets up a testy legislative process that the country might not tolerate. A new set of laws, in the toxic climate of partisan politics, means chaos for the industry just-now adapting to the new normal and default efforts to replace it with "Medicare for All" might take its place. Millennials, cohorts of middle income and hourly workers, with uninsured citizens joining in would be a majority in its favor.

So the likelihood of repeal is low; the inevitable is its repair. And at the top of the list will be several notable hanging chads that might be addressed:

Provisions in the law that de-stabilize the individual insurance market by driving premiums higher at double digit rates annually.

Provisions that tie provider payments to "value" without a consistent methodology for defining and measuring value.

Provisions applying new excise taxes to medical device, drug manufacturers and health insurance companies that they've subsequently passed on in their prices

Provisions that encourage providers toward integrated delivery systems that serve regions without adequate protection and clarity around safe harbors and antitrust constraints

Provisions that address the fragmentation and highly variable performance in post-acute care

Provisions that force employers to provide coverage need attention punishing employers with 50 or more fulltime employees where much of the job growth is stunted by the penalty

And lack of attention in the law to personal accountability, liability reforms, adequate funding for preventive and primary care that's inclusive of mental health, dentistry, ophthalmic care and nutrition, and others

It safe to say the ACA is here to stay regardless of the election outcome. What's also clear is that it will continue to change. Here to stay are its fundamental shift toward provider sponsored risk, increased transparency in all aspects of the system's performance, connectivity through information technologies, comparative effectiveness studies to discern what works best, and insurance reforms that hold companies accountable for business practices that are understood by all.

In Campaign 2016, the ACA will be an issue. It's unlikely it will be repealed and specifics of its repair unlikely to get headline coverage-offering specific remedies in the heat of political contests can be risky.

But lest it be forgotten, healthcare matters to American's and the system's reform has proven to draw voters, especially Millennials who seek reforms and seniors who seek assurance.

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Last Wednesday marked the sixth anniversary of the passage of the Patient Protection and Affordable Care Act. As of this week, the five Presidential aspirants have each articulated key changes they'd propose, though polls show interest in the law is largely among Democrats who consider healthcare a major issue along with national security and the economy.

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meaning: this cartoon is referring to the repeal of obamacare and that it has been the same act in place for many years and their new plan to replace it is the same thing. hence repeat repeat repeat.

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In the weeks following the presidential election, there's been some debate about whether Republicans would actually go through with repealing Obamacare as opposed to getting cold feet. But after a number of conversations with senior GOP leadership aides in both chambers of Congress, this is the message I've received: Republicans are moving full-speed ahead on Obamacare, and could have a bill repealing much of the law on President Trump's desk within weeks of him being sworn into office.

In my conversations with GOP Hill staffers in both chambers, I was actually a bit surprised at their certainty. The basic approach to repeal wasn't portrayed as something that they're still debating, but it was spoken about as something that is definitely going to happen, and as quickly as possible. "The commitment to repealing this thing is ironclad," one House leadership aide said.

As is always the case, there is the risk of roadblocks and delays arising when the House, Senate and administration all have to agree on something. But here's how congressional leadership expects the process to play out, if everything goes according to plan.

The new Congress will be sworn in on Jan. 3 and will immediately get to work on a mid-year budget resolution. The budget resolution would require just a simple majority, and because it's only a resolution, it doesn't require President Obama's signature. All that's necessary is for the House and Senate to pass the same resolution. As a result, this part of the process could take place when Obama is still in office - and Republicans expect to have it finished by the end of their second week back, or around mid-January.

As an actual budget document, it won't have much meaning, as the federal government will already be in the midst of the 2017 fiscal year and spending levels have already been set through the appropriations process - so it's unlikely to be very contentious. Even though it won't have an effect on spending itself, it will be significant procedurally, because the document will be the vehicle for Republicans to include reconciliation language. That language will be necessary for Republicans to pass a repeal bill through the Senate with just a simple majority, thus avoiding any attempt by Democrats to block the bill.

However, because Obama will still have veto power until Jan. 20, Republicans cannot actually pass a repeal bill before Trump is sworn in.

The plan, then, is to move quickly post-inauguration to pass legislation similar to the one they passed this past January, which was vetoed by Obama. That legislation repealed the law's major spending provisions - ending the Medicaid expansion and getting rid of the subsidies for individuals to purchase insurance on government-run exchanges. In addition, the repeal bill scrapped the individual and employer mandate penalties, eliminated the law's taxes and defunded Planned Parenthood. If all goes smoothly, such a bill could reach Trump's desk in short order, as early as February - or weeks after Inauguration Day. Though it's possible that this could slip as certain details get ironed out, there is a determination, among leadership in both chambers, to move with speed.

Setting aside any modifications to the strategy that may be pushed by the Trump administration - always a possibility - the main areas of contention among congressional Republicans are likely to concern how broadly the law is repealed, and when the repeal actually goes into effect.

As far as the scope, some conservatives are likely to push for the repeal bill to go further than it does. The repeal bill that was vetoed by Obama, which would have gutted Obamacare's taxes and much of its spending, did not fully repeal the law, including significant insurance market regulations. Traditionally, reconciliation has been used for provisions with a budgetary impact. Under the complex process, the Senate parliamentarian must determine all provisions that have a budgetary impact, or else those provisions could be struck down, forcing the bill to go all the way back to the House to be tweaked, thus delaying the process considerably.

Obamacare opponents including the conservative activist group Heritage Action, and Michael Cannon of the libertarian Cato Institute, have argued that it's possible to fully repeal the law through reconciliation - including all of the regulations. Options range from asking for the Congressional Budget Office to score the financial impact of regulations to the bolder option, which is to fire the parliamentarian and install a new one who interprets the rules in a way that would allow Republicans to use the maneuver to repeal the whole law.

But among the Senate leadership, there isn't much appetite for such moves. The thinking is that the previously passed reconciliation bill was already pored over by Senate staffers, who considered many different scenarios. What they ultimately came up with repealed much of the law, had the votes, and passed muster with the parliamentarian. Upsetting this delicate balance by adding or subtracting major elements, the thinking goes, would delay the repeal process, potentially significantly. As for firing the parliamentarian (currently Elizabeth MacDonough) though it's true that her job is controlled by the majority party, doing so is seen as out of bounds. One senior Senate leadership aide described it as "a total Reid move," by which the aide meant, it's the type of strong-armed tactic to game the rules that one would expect from former Senate Majority Leader Harry Reid, that would typically make Republicans apoplectic.

The other issue that is likely to cause conflict is the length of the period between the time when the repeal bill is passed and when it goes into effect - i.e., when the federal government formally stops collecting the taxes and cuts off funding for the Medicaid expansion and the insurance subsidies. The temptation of waiting longer is that, in theory, it buys more time for Republicans to come up with an alternative before Obamacare's enrollees start losing their benefits, thus avoiding an endless stream of negative headlines. The downside is that delaying it too long makes conservatives start to worry if repeal is ever actually going to take effect, and in addition, Republicans' power could diminish after the 2018 elections. These tradeoffs will continue to be debated among policy aides on the Hill throughout the repeal process.

Many healthcare experts across the ideological divide have raised potential problems with the "repeal and delay" tactic. Most notably, insurers are currently losing money in Obamacare, and contemplating whether to continue participating. But if they know that the subsidies for people to purchase insurance are going to disappear, there's no reason to stick around. Speeding up the exodus of insurers from Obamacare would mean more people would see their coverage disrupted, likely generating a fierce political backlash as Republicans get blamed for the disintegration of the market.

Republicans I spoke to were dismissive of this criticism. Were such a market collapse to occur, they would argue that Obamacare is really the culprit. That is, under the Obamacare status quo, the individual market is already collapsing. Insurers cannot attract enough young and healthy people to offset the cost of covering older and sicker enrollees, they are losing billions of dollars, and they are rapidly exiting markets, leaving Americans with higher premiums and fewer choices. Left to its own devices, Obamacare as we know it won't survive - and repeal is the first step in fixing the problem, they argue.

One senior Senate leadership aide cited Secretary of Health and Human Services Sylvia Mathews Burwell's description of Obamacare as being like the game of Jenga, as she put it, "if you pull a piece out, you can make the thing tumble." The aide noted that such a statement merely displays the fragility of Obamacare.

Regardless of what happened in the election, one policy aide for House leadership said, the law was already falling apart. "You were looking at exchanges collapsing," the aide said, adding, "There was a lot of work that needed to be done regardless of the actions that were going to happen in the next Congress. Now we view this as stepping into the breach and stopping the pain, frankly, that people are about to experience."

Another issue with a reconciliation bill that wouldn't repeal Obamacare in its entirety is that it would leave in place regulations that could still wreak havoc with the insurance market. One particularly costly regulation is known as community rating, which says that, among other things, insurers can't charge older Americans more than three times as much for insurance than they charge younger Americans. Though in theory this works out well for those who are older, it also makes insurance much more costly for younger Americans - to the point at which they are having trouble justifying purchasing it, despite the mandate to do so. Keeping this regulation in place while repealing the mandate would exacerbate problems in the individual market.

Republicans I spoke with say that such regulatory changes could be tweaked by HHS, as well as handled in subsequent replacement legislation.

When it comes to "replace," Republicans tell me that people need to disabuse themselves of the idea that "replace" means that there will necessarily be one large "replacement" bill. Instead, replacement is going to happen over time through the regulatory process and legislative changes that could be enacted in a series of shorter bills. This is consistent, I might add, with what Republicans have been telling me for years.

Republicans have long thought that one of the drivers of Obamacare's unpopularity has been that it was a massive, complicated bill, that was shoved into law on a partisan basis without people understanding what was in it. Back in 2012, when I prodded Rep. Paul Ryan about replacing Obamacare (as a Supreme Court ruling loomed), he told me, "I don't think it's a good idea to put out some big bill, thump it on the table, that's thousands of pages, and then try ramming it through. That's precisely the process that angered the country so much." Though Ryan is going to let the replace process play out at the committee level, and that could result in a larger bill, this is clearly motivating his thinking, and Senate leadership seems to be in a similar place.

As one senior Senate leadership aide told me, "Replace starts the moment that Tom Price is sworn in as Secretary of Health and Human Services." The text of Obamacare gives the HHS secretary vast power to interpret and implement the law. During the Obama administration, regulatory workarounds have been used to prop up Obamacare, and bureaucrats have picked and chosen which parts of the law to implement (for instance, the employer mandate was delayed and modified without Congress). Republicans now believe that Price, who in the House has been an outspoken critic of Obamacare, will be in a position to turn the tables, using regulatory power to eliminate remaining portions of Obamacare and to start making changes to move the healthcare system in a more market-oriented direction.

Meanwhile, Republicans will work to enact legislative changes that replace aspects of Obamacare - for instance, one bill could theoretically be passed to address individuals with pre-existing conditions.

One problem Republicans are likely to encounter is that any replacement bills not handled through the reconciliation process would require 60 votes, meaning they'd need support of eight Democrats based on the size of the incoming Republican majority. Republicans say that Democrats would be under pressure to join with them, or risk being blamed for not solving problems with the healthcare system. They dismiss talk by Senate Minority Leader Chuck Schumer, who told the Washington Post's Greg Sargent recently, "If they repeal without a replacement, they will own it. Democrats will not then step up to the plate and come up with a half-baked solution that we will partially own. It's all theirs."

Though the debate over the scope and timing of repeal is likely to get passionate, the temptation to quickly get a bill into law that repeals the major tax and spending provisions of Obamacare along with its mandate penalties, may be too great for Republicans to resist, making it easier than usual for them to overcome their differences and swiftly pass repeal, leaving the more difficult task of "replace" until after.

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Here's how Republicans plan to repeal Obamacare within weeks of Trump taking office

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In the weeks following the presidential election, there's been some debate about whether Republicans would actually go through with repealing Obamacare as opposed to getting cold feet. But after a number of conversations with senior GOP leadership aides in both chambers of Congress, this is the...

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Obamacare Repeal: What Happens to People With Pre-Existing Conditions?

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Will Republicans keep the pre-existing conditions provision in Obamacare (The Affordable Care Act)? Here's what could change.

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Meaning that the House of Reps have voted to get rid of ACA while the man on the right represents GOP and their ideas to replace it.

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The Republican Congress and the incoming Trump administration opened 2017 by trying to decide how -- and how quickly -- to repeal President Barack Obama's Affordable Care Act.

What path lawmakers take on repealing and replacing the law will determine the impact on the American public. Here, we'll offer a rundown of what the impact could be, based on analyses by independent organizations published in recent months.

Put simply, these groups agree that a repeal could lead to increases in the number of newly uninsured Americans, the number of people facing difficulties from pre-existing conditions, the size of the federal deficit, and how much money people will have to pay for their health care.
How many more uninsured Americans?
There appears to be broad agreement on this number.

Today, roughly 28 million Americans are uninsured, down from 41.3 million in 2013, due in large part to the Affordable Care Act, with its expansion of Medicaid, the creation of online health insurance marketplaces, the ability of young people to stay on their parents' coverage through age 26, and the mandates that everyone purchase a health insurance plan.

In 2015, the Congressional Budget Office -- the nonpartisan number-crunching arm of Congress -- said that the number of additional Americans who would lose coverage or be unable to get it for the first time would start at 19 million in the first year and increase incrementally before leveling off to 24 million within a couple of years. (The incremental increases would stem from lags in when insurance options lapse as well as increases in the population from young people becoming old enough to secure insurance of their own.)

The major sources of losses would include people no longer able to obtain Medicaid coverage under the law's expansion, and people who would be unable to afford health insurance without the help of federal subsidies currently provided under the law. In addition, the end of mandates would increase the number of uninsured Americans doing so voluntarily, making the personal calculation that they are young and healthy enough to be able to pay less for their own health care needs a la carte than if they bought an insurance policy.

Other groups have come up with similar estimates for the uninsured. This year, the Urban Institute and the Robert Wood Johnson Foundation published a report projecting that 24 million additional people by 2021 would have lost coverage or be unable to find it. The Committee for a Responsible Federal Budget, a group that seeks to lower the federal deficit, projected that the number would be 23 million.

Meanwhile, a 2016 study by the Commonwealth Fund and the Rand Corp. calculated that even the most successful replacement scenario produced an increase in 15.6 million uninsured people, while the most pessimistic would lead to an additional 25.1 million uninsured Americans.

The Urban Institute study further estimated that 66 percent of those losing coverage would have a high school education or less.
How many are at risk due to pre-existing conditions?
Prior to passage of the Affordable Care Act, Americans could in many cases be denied coverage from a new insurer if they had a pre-existing condition. The provision requiring insurers to cover everyone is one of the most popular elements of the law.

But keeping coverage for people with pre-existing conditions while repealing much of the rest of the law is not so easy. When insurers are forced to add patients with pre-existing conditions to their coverage rolls, it costs money. The law handled this by mandating that even young and healthy people who previously had no insurance obtain coverage. But these mandates for everyone to secure coverage are likely to be repealed since they were among the least popular elements of the law. To stay afloat, insurers might have to quit providing insurance or raise premiums for many or all of the people they insure.

The Kaiser Family Foundation projected that if the pre-existing conditions provision is repealed, 52 million Americans could be at risk of being denied coverage in the future.

The foundation concluded that in 11 states, at least three of every 10 non-elderly adults would have this type of pre-existing condition: West Virginia, Mississippi, Kentucky, Alabama, Arkansas, Tennessee, Oklahoma, Louisiana, Missouri, Indiana, and Kansas, states that all voted for Trump.
What would be the impact for people on Medicare?
A full repeal would definitely impact Medicare, the health care program for Americans 65 and over.

For instance, a repeal would restore higher payments for services performed under the managed-care portion of Medicare known as Medicare Advantage, according to the Kaiser analysis. This, in turn, would likely lead to increased premiums for people who are signed up for Medicare Advantage. And an end to the law's guarantees that preventive services be provided free to patients could also raise premiums, out-of-pocket costs, or both.

Perhaps the most notable change would be to reverse efforts to close the "doughnut hole" for prescription drugs. One provision of the Affordable Care Act dramatically cut the amount that seniors on Medicare have to pay for their medicines. (This is known as "closing the doughnut hole" because prior to the law's passage, beneficiaries got some coverage up to a certain dollar amount, and then none until high-dollar, catastrophic coverage provisions kicked in.)
How much more will Americans have to pay out of pocket?
According to the Commonwealth Fund-Rand study, the current policyholder who purchased coverage on the marketplace spends, on average, $3,200 out of pocket annually for the premium and for other costs, such as copayments. It found that repealing the law alone without a replacement would increase out-of-pocket costs to $4,700 a year. Some replacement scenarios could produce a larger increase while some could produce a smaller one, the study said.
What will be the impact on the federal budget?
One might think that repealing a law like the Affordable Care Act would save the federal government money. Actually, in many scenarios, it won't. That's because the law doesn't just spend money -- it also raised revenue through taxes, and it implemented policies designed to keep costs in check. So getting rid of the law also gets rid of the revenue it produced.

While it acknowledged some uncertainty, the CBO estimated that over a 10-year period, repealing the law would increase federal budget deficits by $353 billion. A more recent estimate by the Committee for a Responsible Federal Budget mirrored what the CBO found -- $350 billion over 10 years.

According to the group's calculations, the revenue losses would be driven by rolling back tax increases on the wealthy. About half of the $800 billion in revenue losses would come from payroll and investments surtaxes on wages and income above $200,000 -- a tax windfall that very few Americans could take advantage of after a repeal. Another quarter of the revenue losses would come from repealing fees on insurers, medical-device companies and drugmakers.

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What would the impact be if Obamacare is repealed?

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The Republican Congress and the incoming Trump administration opened 2017 by trying to decide how -- and how quickly -- to repeal President Barack Obama's Affordable Care Act. What path lawmakers take on repealing and replacing the law will determine the impact on the American public.

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Trump Tells Congress to Repeal and Replace Health Care Law ‘Very Quickly’ (Published 2017)

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President-elect Donald J. Trump said he wanted to replace the Affordable Care Act as soon as it was repealed, but some Republicans want more time to consider an alternative.

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trump promises his obamacare replacement plan will cover everybody

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Trump promises his Obamacare replacement plan will cover everybody, report says

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President-elect Donald Trump is putting the finishing touches on an Obamacare replacement plan that aims to provide "insurance for everybody," he told The Washington Post.

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Donald J. Trump made headlines on Friday by saying he would like to keep two components of the Affordable Care Act: allowing young people to stay on their parents' insurance until age 26, and continuing the ban on the exclusion of pre-existing conditions by insurers.

These have long been staples of proposed Republican replacements for the act, but their reaffirmation by the president-elect heightens the importance of understanding what these provisions do, and what they don't.

The ability of young adults to stay on their parents' insurance provided real benefits. It increased coverage by roughly a million people, and improved young people's health. Maintaining this provision is a clear part of any sensible replacement for the Affordable Care Act, and Mr. Trump can do it.

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Information about enrollment in the Affordable Care Act being distributed by volunteers in 2013. Credit Michael Nagle/Bloomberg

Keeping the ban on insurance companies excluding people with pre-existing conditions, however, is a different story. The problem these patients faced was one of the most pernicious flaws of the individual insurance market pre-Obamacare; their exclusion essentially undercut the entire notion of insurance. How is a breast-cancer survivor meaningfully insured if any costs associated with the recurrence of her cancer, expenses that could run into the hundreds of thousands of dollars, are not covered? So it sounds encouraging that Mr. Trump would continue to ban this behavior.

But let's not kid ourselves. Maintaining this popular provision while scrapping the rest of the health care law would be worse for people with pre-existing conditions than repealing the law in its entirety.

To understand why, let's go back to the world of individual insurance before the major provisions of the Affordable Care Act went into effect on Jan. 1, 2014. In that world, the primary source of profit for insurers was not providing better care so that patients stayed healthy, or negotiating better prices with hospitals and drug companies; it was their ability to avoid the sick and insure only the healthy. And insurers had three tools for doing so: denying coverage to the insured for any costs associated with pre-existing conditions; denying insurance entirely to sick people; and charging the sick much higher prices than the healthy, a practice called health underwriting.

If Mr. Trump preserves just the ban on the first of these tools, and allows insurers to reintroduce the other two, he has effectively done nothing. That's because any insurer can simply use the other tools to accomplish the same goal as it could with all three.

Suppose a breast-cancer survivor applied for insurance in Mr. Trump's post-Obamacare world. It's true that the insurer could not offer her coverage that didn't include breast-cancer treatments. But the insurer could simply not sell her coverage at all.

Alternatively, the insurer could offer coverage, but say that any breast-cancer survivor had to pay, say, five times more than everyone else. Both would be perfectly legal if the Affordable Care Act was repealed and replaced under Mr. Trump's principles. If we say that insurers have to pay for breast-cancer treatment for their insured, but allow them to set unaffordable prices or deny insurance altogether, how does that solve the problem?

In fact, Mr. Trump's idea would make insurance markets function even worse than they did before Obamacare. Back then, an otherwise-healthy breast-cancer survivor could at least get insurance coverage for medical expenses not related to her cancer. If Mr. Trump followed through with his suggestion, that would not be possible: The insurer would simply deny coverage altogether rather than take the risk of being forced to pay for treatment for a recurring breast cancer.

So Mr. Trump would not only continue the insurance discrimination that plagued the country before the Affordable Care Act but even make it worse.

In fact, there is simply no Republican replacement for the act that wouldn't leave millions of Americans at serious financial risk. The single most important accomplishment of the Affordable Care Act was to bring the United States into line with the rest of the developed world, as a place where people were not one bad gene or one bad traffic accident away from bankruptcy.

Mr. Trump and other Republicans can discuss kind-sounding alternatives as much as they like, but they can't hide the fact that repealing the fundamental insurance protections that are central to the act would be a cruel backward step.

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Opinion | What Could Be Worse Than Repealing All of Obamacare?

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Donald J. Trump made headlines on Friday by saying he would like to keep two components of the Affordable Care Act: allowing young people to stay on their parents' insurance until age 26, and continuing the ban on the exclusion of pre-existing conditions by insurers.

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On Tuesday, Donald J. Trump said he wanted Congress to repeal the Affordable Care Act right away and replace it with a new plan "very shortly thereafter." But before they abandon all the work that has gone into the health care law since 2010, President-elect Trump and Republicans in Congress owe Americans a detailed explanation of how they plan to replace it. They should not repeal the law until they have submitted their replacement proposal for analysis by nonpartisan authorities like the Congressional Budget Office and the Tax Policy Center to determine how it will affect health insurance coverage, state and federal finances and individual tax burdens.

Vague promises are not enough when we are considering enormous changes in this country's $3 trillion medical economy. Here are seven important questions that Congress must answer about its replacement plan before repealing the Affordable Care Act:

1. How many millions of Americans will lose coverage? The A.C.A. expanded Medicaid coverage to around 12 million people in 31 states and the District of Columbia, and provided financial assistance for moderate-income Americans to buy insurance. These measures have reduced the percentage of Americans who are uninsured to the lowest levels in history. Proposals by Tom Price, Mr. Trump's choice to run Health and Human Services, and by the House speaker, Paul D. Ryan, would repeal the expansion of Medicaid and replace the A.C.A.'s income-based subsidies with less generous tax credits. Another plan from the House Republican Study Committee would offer deductions. We particularly need to know how this would affect low-income Americans, to whom tax deductions are nearly worthless, and who would generally not be able to afford coverage under these plans.

2. Will people over 55 pay higher health premiums for the same coverage? Under the health care law, premiums for older people cannot be more than three times as much as premiums for younger people. But the Ryan plan would let insurers charge older people five times as much. This change, combined with smaller tax credits or deductions that would not compensate for the increased cost, would significantly increase health care costs for many older Americans.

3. Will the new plan let insurers charge women higher premiums than men while offering them less coverage? Before the A.C.A. banned gender-based premiums, insurers in many states charged women more than men of the same age - some as much as 50 percent more. The A.C.A. also required all insurers to cover preventive health services without co-payments; for women, this includes birth control, Pap smears, mammograms and a host of other crucial services. Maternity care is fully covered as well. Republican replacement plans offer no such protection. And many Republicans want to defund Planned Parenthood, too, which would deprive women not just of coverage but also of care.

4. What other services are likely to be cut? Before the A.C.A., about a third of individual insurance market enrollees lacked coverage for the treatment of addiction, and nearly 20 percent lacked mental health coverage. One recent Republican proposal would require coverage only for hospital, physician and emergency care services. Will insurers be allowed to exclude any other services that they choose not to cover?

5. Will the new plan let insurers reinstate annual or lifetime limits on coverage? If so, how would the government ensure that individuals with life-altering illnesses and injuries received care without falling into financial ruin? Before the A.C.A., more than 50 percent of workplace insurance plans had lifetime limits, often in the range of $1 million to $2 million. That sounds like a lot - unless you are a 42-year-old man with leukemia. And "mini-med" policies often imposed annual limits of a few thousand dollars.

6. What will happen to the more than 130 million Americans with pre-existing conditions? Among the most important - and popular - provisions of the A.C.A. are its requirements that insurers cover and not charge higher premiums to people who have pre-existing conditions like cancer.

Some replacement plans propose segregating these people in high-risk pools. Before the A.C.A., two-thirds of states had such pools, which offered health plans with high premiums and deductibles and annual and lifetime caps. The pools never received enough support from the states to respond to the needs of high-cost individuals, and still covered only a tiny fraction of people with pre-existing conditions.

Other plans would protect individuals with pre-existing conditions from discrimination only if they maintained insurance coverage without any breaks. But this is not easy because of job loss and transient hardships. An estimated 44 million Americans experienced a gap in coverage of at least one month in 2013 or 2014.

7. Finally, how much more will those with costly illnesses or injuries have to pay in out-of-pocket costs? Critics of the A.C.A. often argue that the law has made health care unaffordable. But many Americans would pay much more without it. The A.C.A. capped out-of-pocket spending at $7,150 for individuals and $14,300 for families for 2017. Republican proposals appear to offer no protection from high deductibles and other cost-sharing.

This is a short list. One might ask many other important questions about changes to Medicare, Medicaid and insurance bought through employers. Before Congress leaps off the precipice of repeal, Americans have the right to ask, "Where will we land?"

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Opinion | Seven Questions About Health Reform

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On Tuesday, Donald J. Trump said he wanted Congress to repeal the Affordable Care Act right away and replace it with a new plan "very shortly thereafter." But before they abandon all the work that has gone into the health care law since 2010, President-elect Trump and Republicans in Congress owe Americans a detailed explanation of how they plan to replace it.

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ACA repeal can't work without comprehensive plan

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The current Secretary of Health and Human Services admits changes are needed for the Affordable Care Act, but she says Republicans plans to repeal without a comprehensive solution is not in American's best interests. (Jan. 9)

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The funding for many state public health and prevention programs is in jeopardy along with insurance for 20 million people as Congress moves to repeal the Affordable Care Act.

While the ACA requires insurers to cover mammograms, colonoscopies and other preventive care, a less prominent provision authorized a federal fund to prevent the soaring incidence of chronic diseases including diabetes and heart disease. It also funds education targeting college suicides, smoking and low-income new mothers. The ACA's Prevention and Public Health Fund has survived about 60 votes in Congress, and it was tapped to help pay for the recently enacted 21st Century Cures Act, which funds pharmaceutical research and development and opioid treatment.

Supporters worry an ACA repeal could eliminate the fund at a time when it is needed to reduce the $3.2 trillion spent to treat illness and disease with medical services and drugs. On Friday, the House passed legislation that would allow Republicans to repeal all or parts of the law without support from Democrats. House Speaker Paul Ryan said the law would be replaced in a "thoughtful, step-by-step process."

Advocates say it is programs like those covered by the fund that are most needed to prevent and treat increasingly costly diseases.

Diabetes affects nearly 10% of the population or about 29 million people, according to the Centers for Disease Control and Prevention. Of those, more than 8 million people are undiagnosed. The prices for some brands of insulin to treat diabetes, for example, have increased by as much as 60%.

More than 300 public health and patient groups including the American Heart Association signed a letter to congressional leaders last week that warned of the "dire consequences" of repealing the fund without including the nearly $1 billion in other appropriations. "Funding prevention not only saves lives but it saves money," said the letter, citing research by Trust for America's Health that shows every public health dollar leads to a savings of $5.60.

In Louisiana, for example, $9 million from the prevention fund pays for programs including home visits for low income new mothers that reduces costly premature births, lead testing for children under age 5 and education and surveillance for tuberculosis and sexually transmitted diseases, says physician Rebekah Gee, the state's secretary of health.

As public health funding has been cut in recent years, Southern states have seen increases in syphilis, Gee said. Public health workers make sure people get follow-up treatment when they learn of an active case, she said.

"One of the reasons for the fund was to make up for years of chronic underfunding of public health," said Richard Hamburg, deputy director of the non profit Trust for America's Health.

Community programs like those supported by the fund tend to be favored by conservatives who say decisions about the best approaches to health care should be made farther from Washington. But the prevention fund has also been criticized for acting as a "slush fund" for public health, economist Robert Graboyes said

"Emotionally, I tend to like decisions made at state and local level, but states have been as problematic as the federal government," says Graboyes, senior research fellow at the free-market Mercatus Center at George Mason University.

Besides, Graboyes says, "There's a big difference between saying, 'public health funding is important' and saying, 'this fund is a great idea.' " He says it is also too much to expect public health to "undo some of the damage" he believes was done by overly prescriptive laws including the ACA.
Read more: Huge racial disparities persist despite slow infant mortality drop Soaring insulin prices prompt insurance shift
Hughes Melton, a physician who is chief deputy commissioner of Virginia's Department of Health, says "it would be a major setback" for Virginia to lose its federal funding. As state funding for public health has decreased, Virginia has relied more on the prevention fund, he said.

One downside, Melton noted, is the federal prevention fund money comes with "a very specific purpose," so the source dictates how the money is used, not the need.

"It's not that we think the money should be coming from the federal government," Melton said. "We just believe that the needs are real, the services are necessary and the resources are required to provide those services."

Wherever it comes from, states need to be able to rely on the money, Gee said. "Public health is only sexy when you have a coastal evacuation," he said. "But you have to continually invest in it and not just wait for the emergency and say, 'Where is it?' "

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Obamacare repeal threatens public health funding to states

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The funding for many state public health and prevention programs is in jeopardy along with insurance for 20 million people as Congress moves to repeal the Affordable Care Act. While the ACA requires insurers to cover mammograms, colonoscopies and other preventive care, a less prominent provision authorized a federal fund to prevent the soaring incidence of chronic diseases including diabetes and heart disease.