The American Health Care Act (AHCA) narrowly passed a House of Representatives vote on May 4th, after an unpopular first iteration was withdrawn prior to a vote in late March. This new version of the bill, made more palatable to the archconservative Freedom Caucus of the GOP, drastically rescinds the progress attained in American health policy over the past decade.
America long had the shame of being almost entirely alone among developed countries in not providing universal healthcare coverage to its citizens, on top of being the largest spender on healthcare: According to OECD data, healthcare spending accounted for 17.1% of the U.S. GDP in 2013, almost 50% more than the next highest spender, France with 11.6% of its GDP. It is worth noting that France, despite spending much less on healthcare than the USA, successfully provides universal coverage to all of its citizens and ranks ahead of America in overall healthcare performance and quality. Despite astronomical rates of healthcare spending, the USA amongst its OECD peers has comparatively poor population health on multiple measures, like life expectancy, infant mortality and prevalence of chronic disease.
The Obama-era Affordable Care Act (ACA), colloquially known as Obamacare, addressed these public health issues by expanding access to affordable healthcare insurance, through regulation, subsidies, and government-run insurance marketplaces. While it still left the USA lagging behind other affluent nations in terms of healthcare access and was rife with imperfections (many Americans saw their premiums rise and some major insurance providers recently started pulling out of ACA marketplaces), the law was an important victory for Americans. It produced concrete progress: important reductions in the numbers of uninsured in all congressional districts were observed between 2013 and 2015.
Years of rancorous GOP outcry about Obamacare culminated in the American Health Care Act (AHCA), which constitutes the oft-promised “repeal and replace” of the ACA. The AHCA effectively signals a return to pre-Obamacare conditions, as it would significantly restrict access to quality healthcare for millions of Americans.
Though the full extent of the AHCA’s impact on American healthcare is still somewhat nebulous, as it is a complex and multifaceted bill, its main consequences have been estimated in multiple analyses. The Congressional Budget Office (CBO), a nonpartisan federal agency that provides budgetary and economic analysis of legislation to Congress, examined an earlier version of the bill and concluded that it would succeed at reducing the federal budgetary deficit by $337 billion through 2026, which amounts to 4% of the deficit expected over that same period, an inconsequential reduction that does not justify the AHCA’s many negative ramifications.
A less optimistic takeaway from the report is that the AHCA would lead to a substantial reduction in the number of people insured. The initial estimate provided by the CBO is that 24 million Americans would lose their health insurance by 2026, mainly due to changes in Medicaid and subsidies, with the updated version of the bill possibly leading to an even larger drop. This would result in an even higher rate of uninsured Americans than before the ACA was introduced, singlehandedly undoing years of hard-fought advances in health coverage.
Ultimately, this drop in coverage will translate into less medical treatment and heightened death rates. There is an undeniable correlation between mortality and healthcare coverage: the New England Journal of Medicine, through analysis of trends in Medicaid expansion and mortality rates, found that as insurance expanded, for every 455 additional people gaining coverage, one person’s life was saved annually. Assuming the CBO’s estimate of the AHCA stripping coverage from 24 million people is accurate, about 53 000 more preventable deaths can be expected if the AHCA becomes law.
Unsurprisingly, Republican backers of the AHCA like Paul Ryan are selling the bill as a way to “lower costs and increase choices” for everyone, while downplaying its devastating effects on coverage. In reality, changes in net tax benefits from the AHCA would have a disproportionately adverse effect on Americans making less than $10 000 a year, while providing considerable net tax benefits only to those making upwards of $75 000 a year, the Tax Policy Center reports.
Additionally, per the CBO’s analysis, premiums are expected to go down for richer Americans while simultaneously making it tougher for the poor to afford insurance. By charging people with pre-existing conditions more and removing the ACA’s “age rating” provision, which limited the ability of insurers to excessively raise prices for older clients, costs could increase materially for older, sicker Americans.
Modifications to the model for calculating premium subsidies, which is currently based on an individual’s income and would change to one purely based on an individual’s age, would only make the burden of premiums heavier for impoverished Americans. Older, poorer, and sicker Americans will invariably end up worse off if the AHCA institutes these changes. The disproportionate nature of the AHCA’s consequences is by design, as the bill’s budgetary savings and premium reductions for wealthier Americans rely on raising prices for older, poorer Americans, a demographic particularly at risk of death when uninsured.
As mentioned earlier, the AHCA would effectively bring back the practice of charging exorbitant premiums to individuals with pre-existing conditions, which the ACA prohibited through its “community rating” clause. This element of Obamacare required that insurers charge the same premium to all clients within the same geographical area and age bracket, a protection that is scrapped by the AHCA, despite confused claims to the contrary by President Trump.
While the AHCA does not allow insurers to outright withhold insurance from risky clients as was commonplace before the ACA, it decrees the creation of “high-risk pools” in each state, from which people with pre-existing conditions would be able to buy insurance. Analysts and experts, like the Kaiser Family Foundation and the Commonwealth Fund, both nonpartisan policy think tanks, agree that with the current amount the AHCA earmarks to subsidize state high-risk pools, it is an unsustainable solution. Insurers could potentially raise high-risk premiums to prohibitively expensive levels, pricing out millions of Americans from affordable coverage.
The AHCA also includes austere cutbacks to Medicaid, in order for it to deliver on its promise of reducing the federal deficit. The ACA led to the expansion of Medicaid in 31 states and D.C., providing insurance to 11 million previously ineligible Americans. The proposed healthcare law would not only halt Medicaid expansion by 2020, but cap federal funding to state Medicaid programs, resulting in 14 million fewer enrollees, according to the CBO.
As catastrophic as the AHCA may seem, the bill is still a long way from becoming law of the land, and it can still be combated. The current version of the AHCA has not yet been rated by the CBO and could end up covering fewer people or raising premiums more than previous analyses suggested. Moreover, the AHCA will not remain intact for much longer, as many senators have expressed their desire to substantially modify the bill: Finance Committee Chairman Orrin Hatch (R-Utah) explained that “there are undoubtedly going to be some changes” on the Senate floor, as passing the bill in its current form “would be difficult to do.”
Aside from these challenges, the bill faces united opposition from the Democratic Party, suffers from internal strife between the GOP’s various ideological factions, and is massively unpopular among U.S. voters. A significant proportion of the mounting backlash against the AHCA comes from a demographic that adamantly supported President Trump in the 2016 election and would be deeply affected by the bill: rural, lower income Americans with significant health problems and high healthcare spending.
Alongside this bill, a slew of other actions and positions recently taken by the GOP and the Trump administration showcase their thoroughly regressive approach to health policy: the defunding of the UN’s women’s health service, Attorney General Jeff Sessions’ hardline stance on marijuana, and proposed cuts to crucial public health research institutions like the National Institutes of Health (NIH), thankfully avoided for now. The road to humane and comprehensive health policy in America will inevitably be fraught with obstacles like these, obstacles that must be fought at every turn by sensible Americans.