Obamacare: What should stay, and what should go?


— Calling it “a fraud,” “horrible” and “a disaster,” President-elect Donald Trump said that rolling back Obamacare and replacing it with a “much less expensive” alternative is top priority for his administration.

But Americans are divided on what should happen next. One-third of all voters recently polled want the law expanded, one-third want it repealed, and only 9% want the administration to scale back what it offers, according to the Kaiser Family Foundation Health Tracking Poll from October.

The law has always been polarizing. When the Patient Protection & Affordable Care Act, as it is officially known, passed in 2010, it was considered the most dramatic overhaul of American health care in modern history.

Studies show that it has made some people’s lives better. It brought health coverage to 20 million more Americans, taking uninsured rates to an all-time low. It eliminated barriers to coverage and improved some hospitals, and fewer people with health emergencies went bankrupt.

But — and this is a big “but” — there’s a reason former President Clinton called Obamacare “the craziest thing in the world” before he walked that statement back. It has gotten more expensive — too expensive for some. Plan and doctor choices are now more limited. And there’s still a large part of the population that can’t get affordable care because their states chose not to expand Medicaid.

Even President Obama said he’d be open to fixes if Republicans make it “cheaper and better.”

Trump said his repeal-and-replace plan will be a major early priority. Republicans, who have tried to repeal it more than 60 times, could take it up again in January. But some experts suggest that it could take up to two years to change the health care process. And even with a Republican president, it is highly unlikely (PDF) that Republicans will succeed in a total repeal.

What could it be? Trump said he wants something that works better “where your plan can actually be tailored” and wouldn’t merely be a plan to use only if “you get hit by a truck.” He has an eye on cost, too; Trump has consistently said that Obamacare is “far too expensive” for the insured and for the country.

But Trump also told CBS’ “60 Minutes” that he wants to keep some of the more popular parts of the law.

Considering what Trump has said about the plan in the past, what is possible in Congress and what the public seems to love and hate about the plan, here’s a look at what part of Obamacare might make it into Trumpcare.

What many people like about Obamacare

Coverage for people with pre-existing conditions

A popular part of Obamacare is the elimination of insurance companies’ ability to use health status, medical history and gender to determine whether you are eligible for coverage. Nor can insurance companies use your health status to decide what benefits you get or what premiums you’re charged.

Before the ACA, insurance companies could deny insurance to people if they had pre-existing conditions like high blood pressure, asthma, diabetes or even pregnancy. These companies could also charge higher premiums and/or limit the benefits they’d offer to this population.

One in two Americans has a pre-existing condition, according to an analysis from the Centers for Medicare & Medicaid Services. Of those people, 25 million — 46% — were uninsured prior to the ACA.

This part of the law became “one of the strongest assets,” Trump told “60 Minutes,” and he’d like to keep it.

20-somethings on their parents’ insurance

Another popular part of Obamacare: Young people can stay on their parents’ insurance until they turn 26, even if they get married and even if they are not living with their parents.

As the recession made it difficult for young people to find jobs with benefits, this was a popular part of the law when it passed. Since 20- to 24-year-olds have nearly double the unemployment rate of their older non-millennial family members, it remains popular to this day.

Nearly 3 million previously uninsured young people got insurance under their parents’ policies because of Obamacare.

Trump told Lesley Stahl on “60 Minutes” that he will “very much try and keep that.” He added that it “adds cost, but it’s very much something we’re going to try and keep.”

No limits on annual or lifetime coverage

The ACA brought an end to lifetime limits on most plans.

Prior to Obamacare, insurance companies could drop coverage when you were at your sickest. You could actually tap out your insurance resources, and the companies could set a dollar limit on what they’d spend on your care.

Anyone who exceeded their limit was on the hook to pay for their care out of pocket. This part of the ACA was particularly popular with people who needed expensive drugs to fight rare diseases and those treated for cancers that required long hospital stays and lengthy chemotherapy. Many in those communities ended up facing medical bankruptcy, having to foot the bill for their own care.

The ACA ended limits on marketplace plans and on most insurance plans people got through their jobs.

No-cost preventive care

Obamacare allowed insured people to receive some health-care services at no cost. Basic services meant to keep you healthy like blood pressure checks, depression and HIV screenings, flu shots, breastfeeding supplies, mammograms and contraception, among other measures, were all covered.

Contraceptives were the only item in the list that remained controversial, at least for some institutions with religious affiliations.

Immediately after the election, Tweets and Facebook posts warned women that a Trump presidency could limit birth control coverage. Trump hasn’t specifically mentioned what he’d like to do with preventative care overall. In September, though, he said he doesn’t think you should need a prescription to buy birth control.

Improved hospital quality

Incentives in the ACA started to move health care from a fee-for-service model to one that rewards quality of care.

There’s already evidence that Obamacare has improved care quality, studies show. There were real drops in hospital readmissions rates, and 50,000 fewer people died as a result of preventable errors and infections in hospitals from 2010 to 2013, according to White House data.

But there are plenty of parts of the law Trump and others despise that will probably have to change.

What many people hate about Obamacare

The cost

Obamacare is too expensive for too many. In 2015, 46% of the uninsured adult population surveyed said they tried to get coverage but couldn’t afford it, according to a recent Kaiser survey.

The vast majority who get Obamacare, some 85%, get subsidies to make premiums relatively affordable. Those who don’t qualify for subsidies feel the pain of the rise in premiums the most.

Premiums skyrocketed an average of 22% for the benchmark plan in 2017. The spikes are felt unevenly, depending on location. In states where insurers pulled out of the marketplace, the prices went up significantly.

In Oklahoma, for instance, the average premium price went up 69%. In Arizona, premiums more than doubled, and in Indiana, where there is more competition, the benchmark plan is 3% cheaper.

The cost of deductibles went up too, meaning even people who do have coverage often won’t go see a doctor.

Trump said one way he’ll bring down costs is to allow people to buy insurance across state lines. He argues that that encourages competition.

“It’ll be great health care for much less money,” Trump told “60 Minutes.”

Required coverage and fewer choices

Some don’t like being told by their government that they have to have insurance. Over half of Republicans polled by Kaiser said they’d like to repeal the requirement that nearly all Americans have health insurance or pay a fine.

People also complained about the kind of insurance available in marketplaces, especially as the number of insurers shrunk.

To keep costs down, marketplace insurers narrowed their provider networks, meaning people have fewer doctor and hospital options.

Constant plan changes

The shrinking pool of insurers means people often have to investigate new plans when they re-enroll. Filling out additional paperwork and researching options have been a constant source of frustration.

In 2016, 43% of returning customers switched policies.

Small business burdens

Some business groups have complained about the requirement that workplaces with 50 or more full-time equivalent employees must offer health care or face fines. The US Chamber of Commerce said that deters business growth.