What a big Republican win Tuesday could mean for Obamacare

Though the fate of the Affordable Care Act has played a role in presidential elections in the U.S. for more than a decade, this race has been different. Apart from a few cameos, the 14-year old law — often called Obamacare — has been largely off-stage, as immigration, the economy and democracy dominate the fight between Vice President Kamala Harris and former President Donald Trump.

But 45 million Americans rely on the health law for their health coverage — either through private plans or Medicaid — and, in these final days of the race the ACA has returned to the spotlight.

At a campaign stop in Pennsylvania last week, House Speaker Mike Johnson told a crowd that “massive reform” of the health law is needed, adding no specifics. But he did promise a “very aggressive first-100-days agenda” if Trump wins. “Health care reform’s going to be a big part of the agenda,” Johnson said.

As part of a major speech on Tuesday in Washington, D.C., Harris warned Americans of what could happen if the ACA were to be repealed. “You will pay even more if Donald Trump finally gets his way and repeals the Affordable Care Act — which would throw millions of Americans off their health insurance,” Harris said, “and take us back to when insurance companies had the power to deny people with preexisting conditions.”

The upcoming elections could have “enormous” impact on the law, says Larry Levitt, an executive vice president of the nonpartisan health policy research organization KFF. Levitt has studied the ACA since its inception.

“I don't think you can overstate the effect the ACA has had on the availability and the affordability of health insurance in this country,” he says.

He recently shared insights into the ACA’s track record and discussed what “massive reform” from Republicans might look like on the health policy podcast Tradeoffs.
Here are highlights from that conversation.

Interview highlights

On the risks to the Affordable Care Act

If Republicans sweep this election, I think the ACA, along with Medicaid, will have big targets on their back. If Harris wins or Democrats are able to hold on to one house in Congress, I think the ACA will be safe. And even though the ACA has not been a big topic in this campaign, it is still a fork-in-the-road election for the future of the law.

On how  the American public views the ACA

We've been polling for more than a decade and a half about the ACA. … When the ACA was being debated after it passed, it was quite controversial. That changed when Republicans tried to repeal and replace it in 2017. For the first time, the ACA was clearly more popular than not and has grown more popular since then. Now, 62% of the public views the ACA favorably. That's dramatically different than when over half the public viewed it unfavorably. … It's now over a decade since the ACA's main provisions went into effect and more and more people have benefited from the law.

On why the ACA marked ‘a sea change’ in U.S. health care

The impact has been tremendous. If you had a preexisting condition before the Affordable Care Act — a cancer diagnosis, multiple sclerosis, being pregnant, being overweight — if you tried to buy insurance on your own, you would be denied. If it was a mild preexisting condition, you might be offered health insurance, but have to pay a higher premium, or have benefits associated with your health condition excluded from your coverage.

So the ACA was a sea change. Insurance companies have to provide coverage regardless of your health. They can’t charge you a higher premium if you’re sick. And there are a set of essential benefits that all insurance companies have to provide.

Over a quarter of adults under age 65 have a preexisting condition that would have led to a denial of insurance before the ACA. So this is not something that affects a small number of people.

On how the ACA made good health insurance more affordable 

Now, under the ACA, the federal government provides a tax credit that covers at least a portion of the premium for people who are very low-income. … It’s extremely expensive to get health insurance in this country. I mean, health insurance for a family now costs what it would cost to buy a car. For the vast majority [who don’t have job-based insurance], without the federal help to pay a portion of the premium, they simply couldn’t afford coverage.

On why the ACA pushed the overall cost of premiums and deductibles higher

When the ACA went into effect, the price of health insurance policies you buy on your own went up. That’s because insurers had to provide coverage for preexisting conditions, had to provide certain essential required benefits – they had to cover more stuff.

They had to cover mental health. They had to cover maternity. They had to cover substance abuse treatment. All of that costs money. So premiums went up. Now, the [portion of the premium] that people pay out of their own pockets went down. And that’s because of the subsidies the federal government is providing to help people pay for their health care.

On the quality of health coverage since Obamacare took effect

The quality of coverage has, I think, largely gone up. The benefits — the stuff that insurance companies have to provide — are now more comprehensive. It covers preexisting conditions. It covers all of these required benefits.

Now, health insurance generally is still far from perfect. Networks — the doctors and hospitals that insurers cover — are often quite narrow. It can be hard to get an appointment. That’s not true just under the ACA. It’s true for people who get insurance through their employer as well. I don’t think you can pin this on the ACA, but health insurance is certainly not perfect.

On Republican ideas for health care reform 

There are a few different ideas out there. We saw some of this in the comments by Republican vice presidential candidate JD Vance — creating high risk pools for people with preexisting conditions, or creating separate [insurance] pools for people who are sick and people who are healthy.

And if we look back at President Trump’s presidency, his budgets proposed converting both the Affordable Care Act and Medicaid into a block grant to states, meaning removing federal rules and giving states a lump sum of money and giving states flexibility in how to use that money. We’ve seen similar plans, for example, from a group of conservative Republicans in the House that would also convert Medicaid in the ACA into a block grant to states, remove federal protections in the insurance market, and cut federal spending by $4.5 trillion over a decade.

On the trade-offs of some Republican alternatives to ACA coverage — like limited-duration health insurance, association health plans and Farm Bureau health plans

All these ideas have trade-offs. The ACA required mandated benefits. That all costs money, and that raised [monthly] premiums, particularly for younger and healthier people. These ideas — like segregating risk pools or association health plans — have trade-offs in the other direction. People who are young and healthy could get cheaper insurance, but people who are older and sicker would end up paying more.

Tradeoffs is a nonprofit health policy news organization. Dan Gorenstein is the executive editor. Reporter Ryan Levi produced this story for the Tradeoffs podcast. Tradeoffs’ Deborah Franklin adapted this story for web. You can listen to the full interview here: