Table Of ContentNEW ENGLAND JOURNAL MEDICINE
The of
Perspective
January 26, 2017
Repealing the ACA without a Replacement — The Risks
to American Health Care
Barack H. Obama, J.D.
H
ealth care policy often shifts when the coun- ACA have helped slow health care
try’s leadership changes. That was true when cost growth to a fraction of his-
torical rates while improving
I took office, and it will likely be true with
quality for patients. This includes
President-elect Donald Trump. I am proud that my better-quality and lower-cost care
for tens of millions of seniors, in-
administration’s work, through the plan to build on what works be- dividuals with disabilities, and
Affordable Care Act (ACA) and fore they unravel what is in place. low-income families covered by
other policies, helped millions Thanks to the ACA, a larger Medicare, Medicaid, and the Chil-
more Americans know the secu- share of Americans have health dren’s Health Insurance Program.
rity of health care in a system insurance than ever before.1 In- And these benefits will grow in
that is more effective and effi- creased coverage is translating the years to come.
cient. At the same time, there is into improved access to medical That being said, I am the first
more work to do to ensure that care — as well as greater finan- to say we can make improvements.
all Americans have access to high- cial security and better health. Informed by the lessons we’ve
quality, affordable health care. Meanwhile, the vast majority of learned during my presidency, I
What the past 8 years have taught Americans still get their health have put forward ideas in my
us is that health care reform re- care through sources that predate budgets and a July 2016 article2 to
quires an evidence-based, careful the law, such as a job or Medi- address ongoing challenges —
approach, driven by what is best care, and are benefiting from im- such as a lack of choice in some
for the American people. That is proved consumer protections, such health insurance markets, premi-
why Republicans’ plan to repeal as free preventive services. ums that remain unaffordable for
the ACA with no plan to replace We have also made progress in some families, and high prescrip-
and improve it is so reckless. how we pay for health care, in- tion-drug costs. For example, al-
Rather than jeopardize financial cluding rewarding providers who lowing Medicare to negotiate drug
security and access to care for deliver high-quality care rather prices could both reduce seniors’
tens of millions of Americans, than just a high quantity of care. spending and give private payers
policymakers should develop a These and other reforms in the greater leverage. And I have always
n engl j med 376;4 nejm.org January 26, 2017 297
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PERSPECTIVE repealing the aca without a replacement
welcomed others’ ideas that meet Hospitals may have to cut back alongside financial assistance, is
the test of making the health sys- services and jobs in the short run the only proven way to provide
tem better. But persistent partisan in anticipation of the surge in un- affordable, private, individual in-
resistance to the ACA has made compensated care that will result surance to every American. Main-
small as well as significant im- from rolling back the Medicaid taining protections for people
provements extremely difficult. expansion. Employers may have with preexisting conditions with-
Now, Republican congressional to reduce raises or delay hiring to out requiring individual respon-
leaders say they will repeal the plan for faster growth in health sibility would cost millions of
ACA early this year, with a prom- care costs without the current Americans their coverage and
ise to replace it in subsequent law’s cost-saving incentives. And cause dramatic premium increas-
legislation — which, if patterned people with preexisting condi- es for millions more.4 This is just
after House Speaker Paul Ryan’s tions may fear losing lifesaving one of the many complex trade-
ideas, would be partly paid for by health care that may no longer offs in health care reform.
capping Medicare and Medicaid be affordable or accessible. Given that Republicans have
spending. They have yet to intro- Furthermore, there is no guar- yet to craft a replacement plan,
duce that “replacement bill,” hold antee of getting a second vote to and that unforeseen events might
a hearing on it, or produce a cost avoid such a cliff, especially on overtake their planned agenda,
analysis — let alone engage in something as difficult as com- there might never be a second
the more than a year of public prehensive health care reform. vote on a plan to replace the ACA
debate that preceded passage of Put aside the scope of health care if it is repealed. And if a second
the ACA. Instead, they say that reform — the federal health care vote does not happen, tens of
such a debate will occur after the budget is 50% bigger than that millions of Americans will be
ACA is repealed. They claim that of the Department of Defense.3 harmed. A recent Urban Institute
a 2- or 3-year delay will be suffi- Put aside how it personally analysis estimated that a likely
cient to develop, pass, and imple- touches every single American — repeal bill would not only reverse
ment a replacement bill. practically every week, I get letters recent gains in insurance cover-
This approach of “repeal first from people passionately sharing age, but leave us with more unin-
and replace later” is, simply put, how the ACA is working for them sured and uncompensated care
irresponsible — and could slowly and about how we can make it than when we started.5
bleed the health care system that better. “Repeal and replace” is a Put simply, all our gains are at
all of us depend on. (And, though deceptively catchy phrase — the stake if Congress takes up repeal-
not my focus here, executive ac- truth is that health care reform ing the health law without an
tions could have similar conse- is complex, with many interlock- alternative that covers more Amer-
quential negative effects on our ing pieces, so that undoing some icans, improves quality, and makes
health system.) If a repeal with a of it may undo all of it. health care more affordable. That
delay is enacted, the health care Take, for example, preexisting move takes away the opportunity
system will be standing on the conditions. For the first time, be- to build on what works and fix
edge of a cliff, resulting in un- cause of the ACA, people with what does not. It adds uncertainty
certainty and, in some cases, preexisting conditions cannot be to lives of patients, the work of
harm beginning immediately. In- denied coverage, denied benefits, their doctors, and the hospitals
surance companies may not want or charged exorbitant rates. I take and health systems that care for
to participate in the Health Insur- my successor at his word: he wants them. And it jeopardizes the im-
ance Marketplace in 2018 or may to maintain protections for the provements in health care that
significantly increase prices to 133 million Americans with pre- millions of Americans now enjoy.
prepare for changes in the next existing conditions. Yet Republi- Congress can take a responsi-
year or two, partly to try to avoid cans in Congress want to repeal ble, bipartisan approach to im-
the blame for any change that is the individual-responsibility por- proving the health care system.
unpopular. Physician practices may tion of the law. I was initially This was how we overhauled
stop investing in new approaches against this Republican idea, but Medicare’s flawed physician pay-
to care coordination if Medicare’s we learned from Massachusetts ment system less than 2 years
Innovation Center is eliminated. that individual responsibility, ago. I will applaud legislation
298 n engl j med 376;4 nejm.org January 26, 2017
The New England Journal of Medicine
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Copyright © 2017 Massachusetts Medical Society. All rights reserved.
PERSPECTIVE Repealing the ACA without a Replacement
that improves Americans’ care, thanks to the law’s protections. tem. Washington, DC: Council of Economic
Advisers, 2016.
but Republicans should identify Policymakers should therefore
2. Obama B. United States health care re-
improvements and explain their abide by the physician’s oath: form: progress to date and next steps. JAMA
plan from the start — they owe “first, do no harm.” 2016;3 16: 525-32.
3. The President’s budget for fiscal year
the American people nothing less. The Massachusetts Medical Society copy-
2017. Washington, DC: Office of Management
Health care reform isn’t about right applies to the distinctive display of and Budget, 2016 (https://obamawhitehouse
this New England Journal of Medicine article
a nameless, faceless “system.” It’s .archives.gov/omb/budget).
and not to the President’s work or words.
4. Options for reducing the deficit: 2017 to
about the millions of lives at stake Disclosure forms provided by the author
2026. Washington, DC: Congressional Bud-
— from the cancer survivor who are available at NEJM.org. get Office, 2016.
can now take a new job without Mr. Obama is the former President of the 5. Blumberg LJ, Buettgens M, Holahan J.
Implications of partial repeal of the ACA
fear of losing his insurance, to United States.
through reconciliation. Washington, DC: Ur-
the young person who can stay This article was published on January 6, 2017, ban Institute, 2016 (http://www .urban .org/
on her parents’ insurance after at NEJM.org. research/ publication/ implications-partial
-repeal-aca-through-reconciliation).
college, to the countless Ameri-
1. The economic record of the Obama ad- DOI: 10.1056/NEJMp1616577
cans who now live healthier lives ministration: reforming the health care sys- Copyright © 2017 Massachusetts Medical Society.
Repealing the ACA without a Replacement
Allocating Organs to Cognitively Impaired Patients
n engl j med 376;4 nejm.org January 26, 2017 299
The New England Journal of Medicine
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