What will happen if President-elect Donald Trump and Republicans in Congress carry out their pledge to repeal the Affordable Care Act, the 2010 health reform law? By most estimates, up to 22 million people, many of them poor or older Americans, will lose their health insurance.
Mr. Trump seems to recognize this would be disastrous — to an extent. Since the election, he has said that he wants to keep the part of the law that prohibits insurance companies from discriminating against people with pre-existing conditions. Without this provision, insurers can deny those customers coverage, charge them exorbitant rates or refuse to cover treatment for those conditions.
But Mr. Trump and other Republicans are delusional if they think that they can preserve that provision while scrapping the rest of the health care law. Insurers are able to offer policies to people with pre-existing conditions because the law greatly expands the number of people who are insured, thus spreading the costs of treating people with chronic conditions over a larger number of paying customers.
The law provides subsidies to help individuals and families buy policies on government-run online health exchanges (those who do not buy insurance are required to pay a tax penalty). Take away or greatly reduce that benefit and millions won’t be able to afford the plans, and many insurers will simply stop selling policies or will charge individuals and families much higher rates. The law also expanded Medicaid by financing state programs with federal money. Take away that money, and many states will no longer be able to provide care to millions of poor families.
Republicans have said that Congress could vote early next year to repeal the Affordable Care Act but delay the actual end of the law for a year or two. In theory, that would allow lawmakers to come up with a workable replacement while putting off the consequences of repeal.
But any vote to repeal the law would almost certainly cause insurers — which know they won’t be able to depend on the federal government in the future — to start pulling their plans from the online marketplaces for 2018 coverage, kicking millions off coverage. State and local governments will have to start planning to increase spending on public hospitals and charity medical care. Consider this: Uncompensated care at hospitals declined by $7.4 billion in 2014 after most major provisions of the law kicked in, according to the Department of Health and Human Services. Those costs would most likely go right back up.
The House speaker, Paul Ryan, and Republican policy experts have sketched out a variety of replacements for the law, but have not coalesced around one plan. All of them would reduce government spending and slash coverage.
One idea backed by Mr. Ryan would create a government-run high-risk pool to help pay for the medical care of people with major health problems who don’t have insurance. But previous state and federal high-risk pools did not cover most of the people with pre-existing conditions and suffered large losses, according to the Kaiser Family Foundation. Other Republican ideas include expanding the use of health savings accounts, which would primarily benefit wealthy families that can afford to sock away substantial amounts for future health problems.
Those complexities explain why Senator Lamar Alexander, the Tennessee Republican who leads the Health, Education, Labor and Pensions Committee, recently said it would “take several years” to fully replace the Affordable Care Act. Though the law is not perfect, it has greatly increased access to medical care and has made some parts of the health system more efficient by, for example, increasing the use of preventive services.
In discussing the repeal of the law during the campaign, Mr. Trump said, “There will be a certain number of people who will be on the street dying, and as a Republican, I don’t want that to happen.” He might start by following the maxim to “first, do no harm.”