Repealing and Replacing the Affordable Care Act: Prospects and Limitations

By Gorin, Stephen H. | Health and Social Work, February 2011 | Go to article overview

Repealing and Replacing the Affordable Care Act: Prospects and Limitations


Gorin, Stephen H., Health and Social Work


The Republican takeover of the House of Representatives in the 2010 elections raises questions about the future of the Patient Protection and Affordable Care Act (P.L. 111-148), now more commonly known as the Affordable Care Act (ACA). Leading members of the new majority have pledged to repeal the ACA and replace it with "common sense reforms" (Camp, 2010). According to John Boehner (R-OH), the new Speaker of the House, the election gave Republicans "a mandate to cut government and roll back the Obama administration's health care' monstrosity'" (CNN-Wire Staff, 2010). Mitch McConnell (R-KY), the Senate Majority Leader, also expressed support for repeal (Drucker, 2010).

Was the election a referendum on the ACA? Did opponents get a mandate to "repeal and replace" the law? The evidence seems unclear. In the months preceding the election, opinion on the legislation "shifted within a narrow band ... with slightly more in favor in some months and slightly more against in others" (Altman, 2010). In exit polling the day of the election, only 18 percent of voters identified health care as the most important issue; 63 percent identified the economy, and 51 percent of the latter voted for Democrats (CBS News, 2010).When asked whether the law should be repealed, 48 percent of voters said it should, whereas 47 percent said Congress should keep or expand it.

In a Kaiser Family Foundation (2010) poll after the election, 17 percent of voters identified health care as one of two factors "influencing their vote." Of these, 59 percent voted for a Republican candidate, and 56 percent had a "very unfavorable" view of the ACA (Kaiser Family Foundation, 2010). Once again, the economy was the most important factor identified, with health care ranking fourth. It is interesting to note that half or more of Republican voters, who strongly opposed the ACA, supported keeping some of the bill's provisions, including tax credits to small employers to offer coverage to their employees (59 percent), closing of the Medicare prescription drug "doughnut hole" (50 percent), and a prohibition on insurers excluding individuals because of preexisting conditions (61 percent). Among the general public, support for these provisions was even broader. The least popular provision among both the general public and voters, including Democrats, was the mandate requiring individuals to buy health insurance.

In this light, it might seem to make sense for Congress to repeal the mandate and other unpopular provisions and keep only the popular ones. And although this sounds reasonable, the reality is that the law can only work as a whole. Without a mandate, healthy individuals would be tempted "to go uninsured until they get sick" (Krugman, 2010), which would defeat the point of insurance--namely, to spread risk. The result would be "a poor risk pool, leading to high premiums, leading [to] even more healthy people dropping out" (Krugman, 2010). Similarly, without the ACA's cost-containment provisions, including the increase in the Medicare tax on upper income individuals (which 69 percent of Republicans oppose), closing the doughnut hole will be difficult. In short, the law is "indivisible."

Ironically, repealing the ACA could backfire on Republicans. Older adults were a critical factor in the Republican victories in the most recent election, in part because of concern that the ACA would adversely affect Medicare (Surowiecki, 2010). It is true that the law is financed in part by reductions in Medicare reimbursements to some providers and insurers, but these cuts will not affect beneficiaries' access to guaranteed benefits, much less lead to "death panels," as many older adults seem to believe (Altman, 2010; Mahar, 2010). These reductions are also unlikely to compromise the quality of care received by Medicare beneficiaries (Berenson, 2010; Hackbarth, 2007; Mahar, 2010).

Often overlooked, amidst the criticism, is the fact that the ACA extends the life of Medicare's Hospital Insurance trust fund (Part A) by 12 years, begins closing the Part D doughnut hole, expands preventive services (some at no cost), and provides additional subsidies to individuals with incomes below 150 percent of the poverty line (Health Reform's Changes in Medicare, 2010).

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