A week ago, Donald Trump told a crowd in the Philadelphia suburbs that “when we win on November 8 and elect a Republican Congress, we will be able to immediately repeal and replace Obamacare.” Today, with both a Trump presidency and a Republican congress inbound, the Affordable Care Act is in real danger. Just how Trump plans to follow through on a repeal process and what exactly will replace it is anyone’s guess. But a wholesale scrapping would take more away from Americans than they might realize.
People who want to repeal Obamacare tend to be angry about one thing: mandated coverage. The Medicaid expansion and private insurance exchanges outlined in Title I of the ACA have increased coverage by upwards of 20 million people, putting the nation’s uninsured rate at a historic low. Telling people they have to have insurance (especially if the rates they pay help subsidize people who are less well-off) is about as popular with conservatives as the EPA.
But healthcare exchanges and mandatory requirements only make up about a quarter of the ACA’s 955 pages. Buried in the rest are provisions that most people either don’t know about, or actually really like—from small business tax credits to extended dependent coverage to public health programs and rural patient protections. Here’s what a repeal will take off the table:
Obamacare entitles women in private plans access to all 18 FDA-approved birth control options—though some brand-name drugs and devices may only be covered with a co-pay. Right now, birth control costs approximately zero dollars for more than two-thirds of privately insured US women. Women on Medicaid are also covered under ACA, though the failure of at least 19 states to expand Medicaid left many thousands of women without this option. Since 2006, the unintended pregnancy rate has dropped by 6 percent, but remains high among poor minority women who are more likely to require public assistance. In 2010 unplanned births racked up a $21 billion Medicaid bill. Losing free access to birth control would have a significant financial impact on individuals and on the system. So get your IUDs now, while you still can!
The Prevention and Public Health Fund
One of the (really) lesser-known facets of Obamacare is this fund, the federal government’s largest single (and only) dedicated investment in disease prevention. Created by the ACA to improve public health and prevent chronic illnesses, the fund dedicates $14.5 billion over 10 years for programs that reduce people’s risks for things like cancer, diabetes, heart disease, and stroke—diseases that are responsible for seven out of every 10 deaths in America, and are largely preventable. The money goes directly to states for on-the-ground efforts to curb obesity, substance abuse, lead poisoning, and HIV, but it also goes to more large-scale initiatives.
When 1.6 million smokers attempted to quit smoking in 2012 because of the Center for Disease Control’s “Tips from Former Smokers” national ad campaign, that was the PPHF. In fact, more than half of the CDC’s chronic disease budget comes from the PPHF. These diseases represent one of the biggest drains on the health care system—$1.3 trillion in treatment costs and lost productivity every year. “The Prevention Fund is a critically important investment,” says Rick Hamburg, interim President and CEO of Trust for America’s Health, a public health non-profit. “Without it—well, I don’t even want to think about that.”
The Rule of 26
One of Obamacare’s most visible and non-partisan benefits has been allowing young people to stay on their parents’ health insurance plans until age 26. Sure, it hasn’t done much for millennials’ reputations as lazy, self-involved freeloaders, but this feature helped drop the rate of uninsured Americans aged 19 to 25 from 22.3 percent in 2010 to 18.4 percent in 2014. That’s 5.7 million young people gaining coverage in five years. Even Obamacare’s most stalwart antagonists see value in keeping this provision around for the long haul. In June, Republican lawmakers unveiled a proposal to replace the ACA that advocated continuing this provision.
Pre-existing Condition Discrimination
The Affordable Care Act won over some Republicans by telling insurers they could no longer deny coverage to people with pre-existing conditions. Considering that one in two Americans has a health condition that could qualify—asthma, diabetes, cancer, or pregnancy, to name a few—this is one aspect of Obamacare that would have a yuge impact were it to be repealed overnight. Some estimates put as many as 129 million Americans under the age of 65 at risk of being rejected for insurance without this provision of the ACA. Like the Rule of 26, it also made it into this summer’s Republican proposed Obamacare replacement.
Now, none of this is to say that the Affordable Care Act is perfect. It has some very real problems, like not meeting enrollment goals and rising premiums. Any new blood in the Oval Office offers a chance to look deeply and tease out what works and what doesn’t. But it’s also important to recognize that each provision doesn’t exist in a vacuum—they’re built on previous programs that have been around for many years. Untangling them, both pragmatically, and financially, is a tough task. Throwing it all out and just keeping what you like isn’t as simple as it sounds.