ACA as Difficult to Repeal as it was to Pass

Faculty; Policy; Public Health

Despite promises made before Donald Trump’s inauguration, the Affordable Care Act (ACA) — otherwise known as Obamacare — will be as difficult to repeal outright as it was to pass, says a health economist at Washington University in St. Louis.

“This is how Congress works,” said Tim McBride, professor at the Brown School. “The founders of our country set up a system where it is difficult to pass legislation, and that is what the GOP faces now.”

Legislation passing through the Senate needs to get past a filibuster, and shutting down a filibuster requires 60 votes, McBride noted.

“The GOP has only 52 votes, so it would need eight more, and I doubt any Democrats will vote to repeal the ACA completely,” he said. “Furthermore, there are a number of provisions of the ACA that are quite popular with both parties. These include extending coverage to age 26 for dependents on their parents’ policy; banning pre-existing conditions; closing the limitations on drug coverage for Medicare recipients; and expansions of preventive care. The GOP faces a challenge of keeping some of these popular provisions in place while repealing others they do not like.”

What is the future of Obamacare?

“It is quite clear that enacting major changes — if not outright repeal — of the ACA is one of the main objectives the new president and Congress will want to achieve,” McBride said. “He ran on the promise to repeal Obamacare, but I imagine this will include ‘replacing’ Obamacare. Thus, there is a chance that the ACA will be repealed outright, but most experts are assuming that the Congress will pass a ‘repeal and replace’ piece of legislation.”

What form that takes is not entirely clear.

“It appears that Congress plans to pass a piece of legislation that ‘repeals’ the ACA, with a sunset date a few years down the road and then replacing the legislation with something else,” McBride said. “This is because the president-elect and Congress have indicated that they do not want to see about 20 million people become uninsured overnight, since the ACA has decreased the number of uninsured by about that number. And they have not agreed upon a plan yet to replace the ACA without raising the uninsured by millions.”

What will happen to those 20 million people who got health coverage under the ACA?

“If the ACA is repealed completely, there is no doubt among those of us who have studied this for years that the number of uninsured would rise virtually overnight, by up to 20 million,” McBride said. “Under the ACA, the uninsured rate — the proportion of people without insurance coverage — has dropped to a historic low, under 10 percent nationally. If the GOP puts in place provisions that it appears they will offer, it’s not entirely clear how many people will keep coverage or lose it. However, based on what I have seen so far, I would say it’s likely that the policy changes will lead to a significant increase in the uninsured, no matter what is done.”