Repeal of the Affordable Care Act: The Issue Is Not Cost

“Those who need care most often get care least. And even when the poor do get service, it is often second rate…This situation will be corrected only when the poor have sufficient purchasing power to enter the medical marketplace on equal terms with those who are more affluent.”

Richard M. Nixon

Several versions of the Trump / Republican legislation to repeal the Affordable Care Act (ACA, “ObamaCare”) have been released. While the final legislation is not yet available, the general outlines of the Trump / Republican plans are becoming clear.

Before touching on these, it is important to point out – to look back for just a moment – that there is a history of our country trying to bring health care to her people in a manner similar to the ACA.

  1. Presidents, starting with Roosevelt – Theodore, not Franklin – through FDR, Truman, Johnson, Nixon, Clinton, and Obama have all recognized the need to create, in one form or another, additions to our national safety-net that include health care. Obama’s ACA is not new; in fact, it comes from proposals put forward by Mr. Nixon and is more conservative than Mr. Nixon’s health plan (1, 2).
  2. Each time proposals were put forward for a national health program, the criticisms were the same: it is communistic, it is socialistic, it will destroy jobs, it is a government takeover of health care. Always the same, always by the same groups of people.
  3. Health care is complex (!) and expensive. At present, about 17.8% of our gross domestic product (GDP – all the goods and services we make per year) is consumed by health care. Our GDP in 2016 was $ 18.56 trillion, $ 3.2 trillion was spent on health care in our United States. This is unsustainable.

The ACA does need to be “tuned-up”, without a doubt. The heavy emphasis on private insurance markets – no different than what the Republicans are going to do – has resulted in increasing costs and decreased options for people in many of the exchange markets. This is a problem, although not one requiring eviscerating of the ACA to correct.

One major problem with the increase in premium prices and decrease in the number of insurance companies in the exchange markets is with the insurance companies themselves. While companies exiting the state exchange markets claimed that they were doing so because the promised risk payments (held up by this same Congress) were unfulfilled and the risk-adjustment policies were not robust enough (sicker people consume more resources, at least initially), some of these companies – for example UnitedHealth – were simply unable to develop and market new insurance products that worked in this health care market (3). How the Republican efforts will fix this is a remarkable puzzle, as their legislation increases the role of private insurance companies to provide insurance to millions of our citizens. The failure of some of these firms, while others – such as Centene and Molina – succeeded, suggests the failing firms offered a combination of unappealing and small provider networks and higher premiums (3). There is no reason to think, nor data to support, that this will be any different in the Republican proposal.

The ACA provide insurance for about 24 million people who, previously, were uninsured. Today, the number of uninsured Americans is at an all-time low. The plan put together by Trump / Republicans risks eliminating health care insurance and access for between 20 and 30 million of our citizens. These estimates are from the Congressional Budget Office as well as the Kaiser Family Foundation. While the Republicans say these numbers are too high (is 5 or 10 or 15 million of us without health care ok ? What if it was you ?), they have nothing to back this statement except that the “free market will take care of this”.

If decreasing the amount spent on health care, while protecting America’s working people and disabled, were truly the rationale for the Republican attempts to “repeal and replace”, they would choose a “Medicare for All” option. Years ago, it was shown that the private insurance companies in our country consume as much as 30% (30 cents of every premium dollar) in overhead, while Medicare and Medicaid – federal and federal / state programs – consume 5% to 7% for the same (4). Put differently, private insurance companies take 1 dollar and 70 cents goes to your care; the public sector takes 1 dollar and 93 to 95 cents is used to provide care to you.

If the Republicans were serious about cutting costs, this direction – Medicare for All – is the direction in which they would go. Further, something between 20% and 50% of everything we do in medicine is waste – that is, it doesn’t need to be done, but we do it for myriad reasons – we could work together to strip out this waste and protect our economy if this is the reason to “repeal and replace”. But it is not the reason; this is not the direction the Republicans are going either.

To my eye, “repeal and replace” is an attempt to strip health care from our people while enriching the private sector. By turning the health system over to the “free market”, they will only ensure what the CBO and the Kaiser Family Foundation have already warned about: 20 to 30 million of us will lose our health care.

This means certain death for some of us. A recent study evaluating survival in cystic fibrosis showed that Americans were 34% more likely to die than were Canadians with this disease (5). This was due to the insurance coverage differences between the countries. Take 100 people, 34 more will die than should if proper care were given; all because of the way we – or better said Trump and the Republicans – have decided to pay for health care.

This increase in deaths, this attack on working people doesn’t have to be. Is this the America we want ?


  1. accessed 19 March, 2017.
  2. Freed GL, Das A. Nixon or Obama: Who Is the Real Radical Liberal on Health Care? Pediatrics. 2015; 136 (2): 211 – 214 (ePrint ahead of publication: DOI: 10.1542/peds.2015-1122, Volume 136, number 2, August 2015).
  3. Garthwaite C, Graves JA. Success and failure in the insurance exchanges. N Engl J Med. 2017; 376 (10): 907 – 910.
  4. Woolhandler S, Campbell T, Himmelstein DU. Costs of Health Care Administration in the United States and Canada. N Engl J Med. 2003; 349: 768 – 775.
  5. Stephenson AL, Sykes J, Stanojevic S, et al. Survival Comparison of Patients With Cystic Fibrosis in Canada and the United States – A Population-Based Cohort Study, Ann Intern Med.  doi:10.7326/M16-0858.

About AJ Layon

AJ Layon was, for 28 years, at the University of Florida College of Medicine, in the Division of Critical Care Medicine, in Gainesville, FL. For the approximately 10 years until September 2011, he was Professor and Chief of Critical Care Medicine at UF; In September of 2011 he became System Director and Co-Chairman of Critical Care Medicine in PA; this ended in 2017. He served as a Physician in the Surgical Group with Médecins sans Frontières (MSF, Doctors without Borders) through 2018 and is presently an intensivist in Florida, struggling through the SARS-CoV-2 crisis. While his interests are primarily related to health care, health care reform, and ethical issues, as a citizen of our United States and our world, he will occasionally opine on issues of our "time and destiny". Follow on Twitter @ajlayon
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