The Collapse of “Repeal and Replace” and “Just Repeal” – Was There Ever a Plan ?

Now we know. Despite eight years calling for repeal of the Affordable Care Act (ACA) Messers McConnell (R-KY), Ryan (R-WI) and colleagues had no plan, actually no clue, of what to do. This is unsurprising. The ACA is an amalgam of conservative, originally Republican, proposals that were finally operationalized by President Obama.

There are many positives: Insurance markets (exchanges and individual plans) for most people, providing tax credits – more on this later, they aren’t generous enough for working families – so insurance was affordable; Expanding Medicaid for individuals/families unable to enter the insurance market; and a series of tiered insurance products – from a Ford Falcon to a Mercedes, depending on how much you wanted to pay – but with a bottom beneath which no-one slipped. Young adults stay on their parent’s insurance until age 26; No insurance denial because you’re sick; and elimination of lifetime limitations on coverage. Prenatal care and birth control are covered, as they should be in a country purporting to love children.

Some healthy and/or young dislike the mandate: whether an individual or a company, one must have insurance or pay a fine. Disagree, but this is the only way the best parts of the ACA work. In a private/public partnership such as the ACA, to cover all of our people – including those with “pre-existing conditions” – we must have a large pool of healthy, as well as unhealthy, people, or the insurance becomes unaffordable. The mandate is the entire system’s key-stone. We are all obliged to have car insurance, that doesn’t seem to be a problem.

Insurance “buffers”, the technical term is “reinsurance”, were criticized as a “Slush Fund”. Buffers were payments the Federal Government agreed to make to insurance companies if initial premiums were miscalculated; this is neither unfair nor corrupt. There is some complexity in calculating the risk – and hence the premium – for a person who has had limited or no health care their entire life. The reinsurance payments were set for a three-year period to ensure the exchanges/individual markets remained stable if there were early losses; the actuaries who do these calculations would eventually become better at figuring this out, and the payments were to be phased out by 2017 in any event. Further, the payments were to be a combined public/private measure: Federal dollars as well as fees paid by more-profitable-than-expected insurance companies. But Senator Rubio (R-FL) and his colleagues stopped these payments with the Consolidated Appropriations Act of 2016 and, as a result, the exchanges have become unstable. No surprise here, this was vandalism and sabotage masquerading as populism.


We owe Senators Collins (R-ME), McCain (R-AZ) and Murkowski (R-AK) a debt of gratitude as they, plus all Senate Democrats, kept this disaster from becoming law. Imperfect, the ACA was a first step. Although there was no single payer option – Medicare for All – for multiple reasons, it remains an excellent and less costly plan. Concerns the for-profit insurance companies’ profit and administrative cost structure would make the plans too expensive haven’t disappeared; Harvard’s Doctor Steffie Woolhandler noted that private, for-profit insurance companies consumed 30 cents of each premium dollar in overhead, while Medicare/Medicaid consumed 5 to 7 cents; this is but one reason why Medicare for All makes sense.

But let us be crystal clear; facts matter. The plans discussed by the House (American Health Care Act of 2017 [House Resolution 1628], 4 May, 2017) and the Senate versions – the so-called Better Care Reconciliation Act and the “Skinny Repeal” – were never about health reform; they were about stripping health care from millions of us while providing windfall tax breaks to the very wealthy. Fortunately, the voices of many of you demanding this be stopped were heard.

Where do we go from here ? Just let the ACA implode, as Mr. Trump suggests, is the height of irresponsibility. Beyond being cruel, this gets us nowhere.

There are problems with our Health System: It is too expensive and wasteful, and our quality/safety is inadequate and not even well defined – this “unwarranted variation in care” must be tackled. The Federal Government must be allowed to negotiate drug prices. Women’s health, attacked continuously by the Right, must be properly addressed; Planned Parenthood is the source of health care for many working women. Finally, medicine isn’t magic; even in a perfect system, we all eventually die. We must begin a national conversation about end of life care, openly. A single payer option – Medicare for All – is an excellent next step in this process.

In future columns, I will outline our Health System’s problems, drawing on systems judged higher quality than ours. Learning from others, we can craft an improved, responsive American National Health System.

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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