Repealing Obamacare faces these 7 challenges


Republicans have been waiting a long time for this moment. After sixty previous attempts to repeal the Affordable Care Act, commonly known as Obamacare, their moment has arrived. President-elect Trump and Speaker Ryan believe that they can repeal Obamacare and roll back the clock. It won’t happen. Here’s why.

1. Millions will lose health insurance. Pre-Obamacare, nearly 20 percent of Americans went uninsured,  and this disproportionately affected lower-income levels. Those are the exact people who the law targeted. You know those people. They’re the 20 million which Obamacare covers — working 2 or 3 part-time jobs in our new economy and getting coverage from none of them.

What does it sound like when the 20 million who have fallen through the cracks of our employer-based system lose coverage? Not sure, but I’m guessing it will involve lots of clapping, vigorous hand shaking, and hugs.

2. Removing the mandate won’t work. As unpopular as the mandate is, some parts of Obamacare are quite popular. Like how insurance can’t weasel out of covering kidney stones because your kidneys were a pre-existing condition (true story!). If President Trump cherrypicks these good parts and removes the mandate he is going to accomplish one thing: He’s going to Jenga the heck out of America’s private insurance market. Why? Insurance can only be as cheap as the people in the plan. If you remove the mandate forcing healthy people to purchase plans, the costs will continue to increase, and that “death spiral” that Republicans keep talking about is going to become their problem.

3, Your rising insurance premiums. It’s not Obamacare; it’s EpiPens. OK, I can’t really pin this one on Epipens.  The truth is that premium increases have very little to do with Obamacare. The reason behind the increase in our premiums is simple; our health care system is just too damn expensive. My own health care premiums and deductibles started jacking up beginning the year before Obamacare took effect, and have continued to rise since then, as yours have too. As much as many believe it to be so, there is no regulation within Obamacare that would have lead to the dramatic increases we’ve seen in costs. But there are plenty of new technologies that would.

Right now, hospitals all over the country, are replacing their CT scanners with newer ones that are much more sophisticated, more precise, and significantly shinier. They’re also a lot more expensive. Multiply this technology factor by dozens of departments per thousands of hospitals, clinics, and medical offices across the country and you start to get the gist of what I’m talking about here.

But actually, you still haven’t. Because while you’ve heard of EpiPen, you haven’t heard of the myriad drug makers who are busy trying to do the same rebranding and repackaging of their own drugs.

4. Medicare is running out of money. The Medicare trust fund fills the gap between Medicare taxes and benefits. Once the fund is exhausted seniors will pay significantly more out of pocket. In effect they’ll have to think twice — make a call to 911 for that pain in their chest, or make rent?

And check out this hail storm of irony. Obamacare, which may have driven many to vote for Mr. Trump, is also the very thing that prevented that scenario from playing out. The trust fund was slated to run dry in 2016. Election year! It didn’t happen because Obamacare improved Medicare’s fiscal standing, allowing it to remain solvent until 2028.   If President Trump repeals Obamacare, he could effectively move this Medicare calamity to sometime in his presidency.

5. The Obamacare seeds have already been planted. And they’re growing. Many of the programs initiated under Obamacare have already made their way to the larger part of the health care economy. Cost control measures such as increasing deductibles and reimbursement based on quality vs. quantity have become part and parcel of the landscape. Many of these measures are not unique to Obamacare, and most will continue regardless of what happens to Obamacare.

6. Health care has gotten way too expensive. And we have nothing to show for it. You’ve all heard the numbers; we spend about 2 and a half times as much as other industrialized countries on health care. We’re doing too many humanoscans, prescribing too much Godzillamycin, and inserting far too many doohickeys.  Yet, despite this intensive over-care, we don’t live any longer. Actually, our overall health is worse than most other advanced nations. It’s not just insurance companies that are up in arms. The employers that pay for the health care are fed up too, and they are demanding safer and cheaper care from health care providers.

Those increasing pre-authorizations, co-pays, and deductibles you’re seeing aren’t Obamacare; they’re an attempt by payers to try to stop you from asking your doctor about that drug that you saw in a commercial telling you to ask your doctor about it. Because chances are it’s very expensive and isn’t much better than cheaper alternatives.

7. The replacement will still be called Obamacare. Any new plan which President Trump and the Republican Congress put forth will continue to have many of the consumer-friendly benefits of Obamacare. But the thorns will be very difficult to remove. Thus their new plan will still have many of the problems as Obamacare.

But consider this: The public has embraced the idea that every change in their health care is due to Obamacare. So here’s my bold prediction: no matter what they call the new plan, the public will still, some endearingly, some angrily, call it Obamacare.

Ultimately the changes we see in health care are due to the reality that health care has become unsustainably expensive, and despite all our spending, we are not any healthier because of it.  The transformation of the health care market will continue until this explosion of cost has been brought under control, irrespective of whoever’s name is on the law.

Deep Ramachandran is a pulmonary and critical care physician, and social media co-editor, CHEST. He blogs at CaduceusBlog and ACCP Thought Leaders, and can be reached on Twitter @Caduceusblogger.

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