Heide Castañeda, Jessica Mulligan, and Mark Schuller
Wendy and Rich, a white working-class couple from Crystal River, Florida, signed up for Affordable Care Act (ACA, or “Obamacare”) coverage last year primarily because they wanted to avoid paying the penalty. “We weren’t against it,” Wendy recalls. “We just thought we were healthy.”
Now at 61, Rich can’t work anymore. A few months after they enrolled for coverage, his kidneys failed. Wendy, who used to work in food service, only works 20 hours a week since her operation to remove a bone spur. She is 56.
Both Rich and Wendy have “pre-existing conditions,” but are currently guaranteed health insurance through one of the signature components of the ACA. That coverage is now at risk.On May 4 the U.S. House of Representatives very narrowly passed (217 to 213) a measure to replace major parts of the ACA. While it faces an uncertain future in the Senate, the American Health Care Act (AHCA) of 2017 kept alive Republican efforts to repeal the ACA after an initial failure months earlier.
While the FBI probe into the Trump administration’s ties to Russian meddling in the 2016 election reached a crescendo, the Republican-led U.S. Senate has been quietly considering their version of the AHCA behind closed doors and with little media attention. Despite the central importance of women’s health in the law and the disproportionate impact it will have on minority communities, all thirteen committee members charged with writing the Senate version of the bill are white men.
Since its passage in 2010, the repeal of the ACA has been a Republican priority. Particularly controversial has been its provision that mandates individuals obtain coverage or pay a fine. Decried as radical socialism or government overreach, the ACA is actually a pro-market, technocratic reform that expands coverage through private insurance bought on marketplaces or Medicaid for adults up to 138 percent of poverty in expanding states. The ACA also devolved responsibilities to states – a favorite Republican approach to federal policy -- which led to a patchwork approach to coverage expansions. Partly as a result of these factors, along with deliberate sabotage by Republican-led state governments, there are still 27 million uninsured, almost ten percent of the U.S. population.
The ACA was far from perfect, as Mulligan and Castañeda’s forthcoming book details. As a market-based solution, it unevenly expanded access to care and in so doing, addressed some inequalities, while it created, sustained or exacerbated others. It built upon a legacy of existing stratification that had long excluded people from health coverage by class, occupation, race, ethnicity, immigration status, gender, and sexuality. When “Obamacare” outlawed some of these discriminatory practices (such as charging women more for insurance), it became a vehicle for generating hostility toward women, immigrants, the poor, and racialized minorities. Politicians skillfully used this resentment to attack the law, most notably during the 2016 election in which Trump ran on a platform of repeal and replace.
There are a number of “lessons learned” from the first five years of the ACA that could be readily used in amendment or replacement efforts. For instance, enrollment processes could be streamlined. Policymakers could simplify the system and remove some of the burdens and responsibilities on those that need health care the most. Another example of positive reform would be to close existing coverage gaps—in non-Medicaid expanding states, there are currently no affordable insurance options for adults earning below 100 percent of the federal poverty level. The AHCA bill passed by the House will deteriorate the consumer financial support and protections created by the law, including for those with preexisting conditions, and if implemented, will also increase stratification, primarily by state of residence, income, gender, and race.
The AHCA does not fix the health care system, it makes it worse. For all its flaws, Obamacare at least acknowledged that it was in the government’s interest and responsibility to ensure access to basic health care. The U.S. is the only economically advanced nation that doesn’t have universal health care. When the Congressional Budget Office released its estimates last week, it became clear just how vicious and partisan the bill was designed to be, rather than in the interests of the American people. It will leave 23 million more people uninsured by 2026 than if the ACA were to remain in place.
Other organizations, including mainstream and even conservative groups have conducted their own analyses. The nonpartisan Kaiser Family Foundation examined the potential impact of the AHCA on people with pre-existing conditions, like Wendy and Rich, as well as its effect on premiums and deductibles for consumers. According to their projections, premiums will rise for lower income and older enrollees. States will also have the ability to waive certain consumer protections like the essential health benefits package and community-rated pricing for those with pre-existing conditions. The American Medical Association declared to Congressional leaders that the AHCA is critically flawed. The American Association for Retired Persons, to whom Republicans appealed in their attacks on the ACA, also opposes the AHCA.
Meanwhile, as efforts to repeal and replace have finally found footing in Congress, public support for the ACA is soaring, reaching its highest point in February since the law’s passage in 2010.
Given this public support for the ACA, why does it continue to be the Republican’s main target, and only legislative “success” in the new administration? Two central interests seem to be tax cuts for the wealthy, and a devolution – “deconstruction” – of the federal government, in favor of states’ rights. Both have been consistent themes of the radical right’s agenda since the Civil War and Civil Rights.
There are alternatives. While a single-payer system remains the most efficient and equitable option, there are many paths to universal coverage. There are models for universal coverage that have varying degrees of private insurer participation (Germany and the Netherlands, for example). Our conversations need to expand. The AHCA simply leads to less comprehensive coverage, fewer people with insurance, and no progress made to control our skyrocketing health costs beyond selling people coverage with higher deductibles that covers less.
Because of its focus on state-level decision-making, this is where the fight is being waged right now, by organizations such as the Florida Policy Institute, Florida CHAIN, and Protect Our Care Illinois. To resist a disastrous AHCA in our future, voters need to be sure the deliberation process is visible and consequential for legislators from their home states. Similarly, state leaders should insert themselves into this conversation, especially those from states that expanded Medicaid and have the most to lose.
For now, Wendy is in limbo, and very nervous. “If Trump gets rid of the ACA, he will kill my husband.”
Heide Castañeda is an Associate Professor in the Department of Anthropology at the University of South Florida. Jessica Mulligan is Associate Professor of Health Policy and Management at Providence College. Mark Schuller is Associate Professor of Anthropology and Nonprofit and NGO Studies at Northern Illinois University.