Sie sind auf Seite 1von 10

The Affordable Care Act Obamasnare

The Republican Congress scrambles to find an alternative to Obamacare

From the print edition | United States


THE last time President Barack Obama counted, congressional Republicans had tried to repeal parts of the
Affordable Care Act (ACA), his health-care law, more than 60 times. Donald Trump’s election victory means
their efforts will no longer be in vain. Yet despite Republicans’ confidence in Obamacare’s shortcomings, what
exactly will happen to the law when Mr Trump takes office remains something of a mystery.

Because Republicans lack the 60 votes necessary to overcome a filibuster in the Senate, they will be unable to
pass a comprehensive health-care bill without Democratic votes. Instead, they must rely on a process dubbed
“budget reconciliation”, which allows a simple majority to pass tax-and-spending measures. Republicans used
this process to send a law repealing parts of Obamacare to the president’s desk. Mr Obama vetoed it early this
year. Next year, President Trump will probably sign it.

That will be the beginning, rather than the end, of the Republicans’ task. On its own, the reconciliation bill is
best described as a wrecking effort. It would remove the subsidies currently available to poor buyers on the
ACA’s insurance exchanges. It would nix the individual mandate, which fines Americans who can afford
health insurance but go without it. Both moves would reduce the number of healthy people buying coverage.
But a rule banning insurers from turning away those with pre-existing medical conditions would remain. As a
result, premiums, already up by an average of 22% this year, would rise further, deterring yet more healthy
customers. The “death spiral” that some say already afflicts the exchanges would thus accelerate.

Eventually, there would be no market left to serve those who are not covered through their employers or by
other government programmes. This includes 12m people who currently buy on the exchanges, and 9m who
purchase directly from insurers. As well as killing the individual market, the bill would also undo the expansion
of Medicaid, government-provided insurance for the poorest, which was largely responsible for the fall in the
number of uninsured Americans after the ACA was passed. Such a painful death for Obamacare would not
reflect well on the executioners.

But congressional Republicans are betting that, with the individual market likely to crumble, Democrats would
have no choice but to support a full replacement. The best guess as to what that might look like is a somewhat
vague plan penned by Paul Ryan, Speaker of the House. This includes replacing Obamacare’s targeted
subsidies for the poor with a universal tax credit increasing with age.
You might think that replacing means-tested help for poor buyers with a universal benefit would raise costs for
the government. But Republicans insist that with enough deregulation, premiums will fall dramatically. For
instance, the ACA forces all plans to include certain benefits, such as preventive care, and limits the extent to
which insurers can vary prices with risk.

Freed from regulation, insurers are likely to design plans which appeal only to healthy buyers. Mr Ryan’s fix is
to put unhealthy people into “high-risk pools” with higher premiums and big subsidies. States have tried high-
risk pools in the past, notes Gary Claxton of the Kaiser Family Foundation, a think-tank. Typically, premiums
were capped at 150-200% of standard rates. But because that was too expensive for many folk, only the very
sickest people—say, those with HIV—bought coverage. This pushed up the average subsidy per enrollee. Mr
Claxton says big subsidies concentrated on few people could sap the political will to support the pools.

Whatever Congress decides to do, it must move quickly. Few insurers will want to remain in a wobbly market
with an uncertain future. Mr Trump’s changeable views complicate matters. He now says that he wants to
retain the rules on pre-existing conditions, which Mr Ryan would phase out. Having spent so long diagnosing
the ills of the ACA, the Republicans must now agree on a cure.

The Economist explains Why Republicans hate Obamacare
Why is the Affordable Care Act so despised by so many conservatives?

The Economist explains

Dec 11th 2016

by M.J.

IT HAS been called “the most dangerous piece of legislation ever passed”, “as destructive to personal and
individual liberties as the Fugitive Slave Act” and a killer of women, children and old people. According to
Republican lawmakers, the sources of each of these quotes, the Affordable Care Act (ACA), or Obamacare, is a
terrible thing. Since it was passed by a Democratic Congress in 2009, it has been the bête noire of the
Republicans. The party has pushed more than 60 unsuccessful Congressional votes to defeat it, while the
Supreme Court has been forced to debate it four times in the act’s short history. Obamacare was also at the
heart of the two-week government shutdown in 2013. Why does the ACA attract such opprobrium from the

Republican distaste exists for ideological, economic and historical reasons. Start with the ideological. The
fundamental mechanism behind Obamacare—that Americans who can afford to buy insurance directly from a
provider are charged higher premiums to help to pay for the subsidies provided to those who buy their coverage
from government-run marketplaces—is the sort of redistributive economics that is anathema to the party of
small government. Many conservatives, including Tom Price, Donald Trump's pick as health secretary, see the
drive for universal insurance as evidence of government meddling in the private doctor-patient relationship.

Next, they argue that the economics of Obamacare do not stack up. This is contentious. On one hand, the
proportion of Americans without any sort of health insurance has declined from a high of around 16% in 2010
to 11% in 2016, according to Gallup, a pollster. New numbers suggest that the uninsured population among
low-income white people without a college degree has dropped from 25% in 2013 to 15% this year. A large
group that voted for Mr Trump is also among the biggest beneficiaries of Obamacare. On the other hand,
premiums are set to shoot up in 2017, by an average of 22%. Many insurers have lost money on the exchanges
as customers have been older and sicker than they expected. Insurers are, in turn, passing on this cost to better-
off Americans. Republicans argue that it represents the beginnings of market failure: higher prices will deter
healthy, young Americans from signing up, which means insurers will make further losses, which means prices
will rise again and so on, until the system collapses. The government maintains that premiums are what the
Congressional Budget Office expected they would be, prior to the launch of Obamacare.
Lastly, many on the right view the ACA as the latest round in a multi-generational fight against state-proffered
health care. Early in his presidency, in 1945, Harry Truman called for an “expansion of our existing
compulsory social insurance system” to include health care for every American. The American Medical
Association led the charge against it, and its PR firm coined the perfect phrase to sink it: “Socialised
medicine”. It was political dynamite in a furiously anti-communist age. When the Republicans seized control of
Congress in 1946, the policy was dropped. The government used tax breaks to encourage firms to offer private
insurance plans. Workers took them up and health-care provision became entwined with employment.
Subsequent Democratic presidents—Lyndon Johnson, Bill Clinton, Mr Obama—have pushed the government
further and further towards universal health-care provision, but the resistance has been strong. The label of
socialised medicine stuck as fast to Obamacare as it did to Truman’s plan. Mr Price may well resurrect it again
in 2017.

Health care in America Don’t kill Obamacare
As the Supreme Court considers whether to gut Obamacare, evidence is mounting that the law is working

From the print edition | Leaders

Mar 5th 2015

AMERICA’S health-care system is the costliest in the world, gobbling up 17% of GDP. The average for rich
nations is only 9%; even the French spend less than 12%. Despite this avalanche of cash, one American in ten
has no cover and American life expectancy, at 79, is four years worse than Italy’s.

The Affordable Care Act of 2010, better known as Obamacare, was supposed to deal with these problems. Five
years later, Barack Obama’s most important domestic reform is unpopular (56% of Americans disapprove of it)
and under renewed attack. This week the Supreme Court heard yet another legal challenge. In King v Burwell,
the law’s opponents argue that its subsidies for individuals buying health insurance on the federally organised
online exchanges are illegal (see article). They are unlikely to prevail but, if they do, the law will be gutted and
the insurance market thrown into turmoil.

That would be a terrible shame, for Obamacare appears to be working better than expected. First, despite the
incompetent rollout of (the website that allows people to use the federal exchanges), the
proportion of Americans who lack cover has fallen from 16.2% to 12.3% since 2009. Second, the previously
terrifying pace of medical inflation has slowed. The amount that America spends on health care grew by 3.9%
a year in nominal terms between 2009 and 2011—having grown by 7.3% a year in 2000-08. The trillion dollar
question is: how much of this squeeze is because of Obamacare?

Not all, clearly. The economic downturn accounted for much of the fall in health-care inflation: 77% by one
estimate, 37% by another. Yet Obamacare also played its part. For one thing, it may have helped trim some of
the fat from Medicare, the bloated public-health scheme for the old. Many hospitals appear to have changed the
way they behave in anticipation of the law. The old rule of thumb for American health care—and particularly
for Medicare—was that doctors were paid for every test and surgical procedure, and so performed many that
were unnecessary. The new law has provisions that encourage them to keep people well; for example, it
imposes penalties on hospitals where patients are frequently readmitted. Hospitals are merging, streamlining
and restraining their enthusiasm for buying all the latest expensive equipment (see article). A new paper
in Health Affairs shows that they have improved productivity in the past decade, and especially since 2009.

Annual spending per Medicare beneficiary has fallen in real terms from $12,000 in 2011 to an estimated
$11,200 in 2014. This is highly unusual—the last time Medicare spending fell was in the late 1990s. Granted,
Medicare beneficiaries are healthier than they were, since swarms of baby-boomers have pulled down their
average age. But the programme has also grown more efficient. The Congressional Budget Office projects that
Medicare spending per head will be no higher in 2020 than it is now. By then, spending on Medicare and
Medicaid (cover for the poor) could be $160 billion a year less than previous estimates. In the wider market,
too, health inflation is subdued (see article).

Plenty more flab to trim

As Americans age and Obamacare continues to extend coverage, federal outlays on health will probably start to
grow again as a share of GDP over the next decade. America still spends far more than it needs to on health
care, as the gap with other nations shows. But there is hope at last that health inflation can be made more
manageable. Scrapping Obamacare and starting again from scratch would make this harder. Far better to build
on what appears to be working. For the Supreme Court to rule for the challengers would be a woeful outcome.
Is Obamacare helping or hurting the average U.S. citizen?

Steve Murch, independent voter

Updated Jan 4 · Upvoted by Bill Bateman, I've been selling health insurance since 1980 (ish) in multiple states. and Grayson Young, RN, BSN. Coronary ICU
The Affordable Care Act, if honestly represented, is a redistribution-of-wealth program that significantly altered the private health
insurance market with a primary goal of providing greater subsidized coverage for lower-income individuals.

As with all wealth redistribution plans, there are clear winners and there are clear losers. Is the average American a clear winner or a
clear loser? While valid arguments could be made either way, I think the balance of data suggests to me that middle-class Americans –
average US household income is around $51,000 – are hurt through much higher out-of-pocket costs, much narrower choices and
disruption, plan cancellations, extra tax forms, being forced to pay for unwanted services in some cases, and high downstream unfunded
costs. And for those not on it (which is likely for the average American, given only 12 of 350 million citizens are), it explodes state
Medicaid budgets and fiscal liabilities at the federal level, so they are hurt by it too. This negative view is bolstered by the fact that it has
never been majority-popular by any significant margin, and more people disapprove than approve of it, several years in.

One middle-class American explained it this way: “Unless I’m catastrophically ill, I’m now required to spend $12,000 for the privilege of
spending another $10,000 per year out of pocket on medical care.” That sums it up for our family too – though $12,000 per year is
cheaper than what we're paying.

Most important, perhaps: the entire program is at high risk of actuarial failure in the next ten years if nothing is done.

Secretary Clinton confidently asserts that the ACA is “clearly working.” It seems to me we first need to understand how she defines

When I pay for a refrigerator, computer, or service, I decide whether it's working based not solely upon what these products happen to do
when I get them –the unexpected new features and whatnot – I also compare what I got to the representations that were repeatedly and
earnestly made by its salespeople. A noisy refrigerator with a broken freezer compartment isn’t “working” if I was repeatedly sold on it
with promises of it being quiet and ice cream-ready.

In essence, I ask myself, “Was the advertising honest?” We all do.

To that end, these promises were repeatedly made about the ACA:

1. “If you like your healthcare plan, you can keep your plan, period.”
2. “If you like your doctor, you can keep your doctor, period.”
3. “The typical family of 4 will save about $2500/year.”
4. “We can do all this without adding one dime to the deficit.”
5. “A site as easy to use as Amazon.”
6. “We predict 21 million people insured by the ACA in 2016.”
7. “23 government-sponsored healthcare co-ops will help deliver better access to care.”
8. “This is not a tax.”
These are not minor representations about how the ACA would work. They were, and are, important commitments that were repeatedly
made. They were repeated so often because they resonated. They mattered to people. People who dared raise questions about any one of
them were scoffed at, even mocked.

The president even said before both houses of Congress, “If you misrepresent what's in this plan, we will call you out.”

No doubt these repeated, forceful assurances caused some of us to go from opposition to support – though it remained highly divisive and
still never earned significant-majority popular support.

Some of us likely reasoned that surely, the biggest representations, many made after the details of the ACA were known, couldn't
possibly be so blatantly lied about. After all, in many instances when these assurances were made, the ACA was either in final statute
form or even already law.

It's late 2015. Here's the tally:

1. Broken. Called “Lie of the Year”, in fact.

2. Broken.
3. Broken.
4. Broken.
5. Nope.
6. It's a year away, so we don't yet know, but enrollment predictions have just been halved to 10-11 million.
7. 12 of the 23 have already declared bankruptcy, taking with them billions of dollars in taxpayer-funded loan guarantees.
8. Broken (see Supreme Court.)
On each of these important representations, the ACA is most definitely not working.

Yes, there are several laudable goals and even accomplishments of the ACA. And even if you subtract out the millions of people who
involuntarily had their healthcare insurance cancelled on them (including my family of five), it does look like it has net-expanded the
number of people that have gotten insurance, at a price.

On the flip side, about 70% of new ACA enrollees are under Medicaid, which is 100% subsidized; they essentially pay nothing to support
it. Many of the remaining 30% also get some form of subsidy. A 2015 McKinsey study indicates that insurers are currently taking $2.5
billion in annual losses through the program. UnitedHealth, the largest participant in the ACA marketplace has said their losses are about
half a billion dollars and are unsustainable, indicating they will likely exit the market next year. Cigna, another large insurer, also
confirmed that they are taking losses with the program. Two significant sources of revenue – the “Cadillac Tax” and the Medical Device
Tax – are likely going to be repealed soon, primarily at Democrats' urging.

So, given the above, can you help me understand the math that still makes this program work, while also adhering to promise #4 above? I
realize it’s complex – Professor Gruber might even say it’s opaque, or remind me that I’m stupid – but even I just can’t grasp the basic
math that keeps this program afloat in the long term to foot without continued massive increases in deductibles, out-of-pocket costs,
narrowing of choices, or expansion of the federal debt.

Yes, the ACA has removed the legality of plan cancellations based upon pre-existing conditions, a huge and largely positive change in

Secretary Clinton, to be honest, I think your characterization that it’s “clearly” working at a minimum has to be balanced against whether
it’s actually delivering on the repeated promises that were made about it when it was put forward. And doing so, it's far from clear that
the ACA is “working” as promised or even as represented.

As mentioned above, the ACA, if honestly represented, is a redistribution of wealth law that reshapes the health insurance market. There
are winners and losers. Many of those of us in the latter camp do support the notion of improving America's healthcare, but we also wish
we weren’t so blatantly and repeatedly lied to, inconvenienced, price-hiked and insulted. We’re footing the bill for much of this, and at a
minimum deserve a little respect – which starts with honesty. And then maybe even if any ACA fans are so inclined, a bit of gratitude.

Secretary Clinton, I appreciate you (or your staff) participating directly on Quora.

If you're a reader and some of my thoughts above resonate with you, and you aren’t too busy figuring out where to spend your $2500
savings this year, I’d be honored if you added your voice by clicking the “Upvote” button.

Related reading:

Obamacare Is Now on Life Support

Obamacare Enrollees Are Reeling from High Deductibles

Latest ObamaCare Flop: Enrollment Will Be Way Below Plan

The Biggest Threat To Obamacare Is Already Written Into Law: No Insurance Industry Bailouts
11.5k Views · View Upvotes

É de se esperar que quem formula uma proposta de mudança seja capaz de oferecer um
modelo que resolva problemas existentes e não crie outros novos, ou pelo menos ofereça um
saldo positivo em relação aos benefícios que vier a produzir e as dificuldades que gerar.

Situação e problemas do Obamacare - controvérsia - a opção ideológica pelos pobres ou pelo


1. President TrumpConta verificada @POTUS 1 minHá 1 minuto

The time has come to give Americans the freedom to purchase health insurance across state lines! #JointAddress

47 respostas283 retweets888 curtiram

2. President TrumpConta verificada @POTUS 3 minHá 3 minutos

We must ensure that Americans with pre-existing conditions have access to coverage. #JointAddress

401 respostas760 retweets2.834 curtiram

3. President TrumpConta verificada @POTUS 4 minHá 4 minutos

Obamacare is collapsing – and we must act decisively to protect all Americans. Action is not a choice, it is a necessity.


426 respostas877 retweets2.960 curtiram

4. President TrumpConta verificada @POTUS 7 minHá 7 minutos

I am calling on Congress to REPEAL & REPLACE OBAMACARE with reforms that expand choice, increase access, lower costs
& provide better care.


Indutores de custo - o problema dos incentivos divergentes - corolários de primeiro nível -

corolários de segundo nível -