Who loses if Obamacare is repealed? Just about everyone

As the new 115th Congress took office in early January, its Republican leaders were beginning the process of enacting legislation to repeal the Affordable Care Act (ACA) in stages, using a process that has been called repeal, delay, and replace. Essentially, repeal, delay, and replace involves Congress repealing the ACA's key coverage programs, the taxes to pay for them, and individual and employer coverage mandates through procedural legislative vehicles that cannot be filibustered by Senate Democrats, so that repeal of much of the ACA can be passed by simple majority votes.

In an attempt to avoid any disruption in coverage for the millions now covered through the ACA, the repeal bills would delay the date when most of the coverage provisions—including premium and cost-sharing subsidies to buy coverage in the individual insurance market, and funding for states that have expanded Medicaid—would actually expire by several years (how many years was yet to be determined at the time this article was written), thereby giving the lawmakers time to come up with a replacement.

Yet it probably won't work out that way. As I wrote in a recent commentary published in Annals of Internal Medicine, online, it's magical thinking to believe that one can repeal the ACA, delay the repeal from going into effect, avoid loss of coverage, and then replace the ACA with something that keeps the popular parts while jettisoning the unpopular ones. However, there is little doubt that President Trump and the Republican congressional leadership will continue to try.

Notwithstanding their pledges that no one's coverage will be disrupted, the reality is that if Congress enacts repeal, delay, and replace, many millions of Americans—far more than most realize—will be at risk of having health insurance coverage taken from them. In fact, I recently took it upon myself to see how many are at risk and concluded from independent and nonpartisan studies that that there are at least 50 ways that people could lose their health insurance (my apologies to songwriter Paul Simon) if the ACA is repealed. You can read them all in my Dec. 15 ACP Advocate blog post.

What especially stood out to me, though, are the following five categories of people most at risk of losing coverage:

1. People who get coverage directly from the ACA, many of whom were previously uninsured. If Congress repeals the ACA's funding for Medicaid expansion and its premium and cost-sharing subsidies to buy private insurance, as many as 22 million people, most of them lower-income, could lose coverage.

2. People with pre-existing conditions or occupations that, before the ACA, were considered “declinable” for coverage. Approximately 52 million Americans, 1 out of 4 people, have a “declinable” medical condition, including very common diseases like diabetes or asthma; if the ACA is repealed, they could again be excluded from coverage. And before the ACA banned discrimination against pre-existing conditions, people with certain occupations, like miners, EMT first responders, baggage handlers, or off-shore oil drillers, could also have been declined coverage because their jobs place them at greater risk for work-related injuries.

3. Women. If the ACA is repealed, insurers would again be able to treat being female as a pre-existing condition, allowing them to charge women higher premiums. They could exclude coverage for maternity care and breastfeeding support, supplies, and counseling and contraception; high-risk human papillomavirus (HPV) DNA testing every three years, regardless of Pap smear results; gestational diabetes screening; and HIV screening and counseling, all benefits now guaranteed by the ACA. And women who are survivors of domestic and sexual abuse (men too) could be denied coverage, because many insurers considered being a survivor of abuse to be a “declinable” pre-existing condition prior to the ACA.

4. Working-class people who live in red (Republican-leaning) states. Fifty-six percent of those at risk of losing coverage from ACA repeal are white, most from the working class. Included in this category are the 2.5 million people in GOP-represented states who are enrolled in Medicaid as expanded by the ACA.

5. People with mental and behavioral health conditions and/or substance use disorders. Some 60 million people suffer from such conditions. Under the ACA, mental health is an “essential benefit” that insurers must cover to the same degree as they cover other medical care. The ACA also prohibits denials for people with pre-existing conditions, including mental illness, and mandates coverage of specific services related to behavioral, mental health, and substance use disorder treatments. Largely due to the ACA, the uninsured rate for adults with “serious psychological distress” dropped from 28.1% in 2012 to 19.5% in the beginning of 2015, according to the most recent figures from the CDC.

So while some in Congress may claim that ACA repeal is no big deal, that everyone will be taken care of while they come up with something “better,” the facts tell a different story: Just about every one of us will be adversely affected. Because we ourselves or someone we know is a woman, or working class, or suffers from behavioral health and substance use disorders, or has (or in the future will have) a pre-existing condition, or gets coverage directly from the ACA, or falls into one of the many other categories of people who could have coverage taken from them. For them, for us, 2017 will be anything but a happy new year if Congress repeals the ACA.