“For every complex problem, there is an answer that is clear, simple and wrong.” – H. L. Mencken
“Simple is never that simple.” – Philip Roth
On the campaign trail, it sounds so simple. The Republicans who now control the three branches of government have said over and over again they will repeal the Affordable Care Act and replace it with something “terrific.”
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Everyone is aware of the possibility that the state exchange individual insurance market will be disrupted. In fact, the Congressional Budget Office estimated this week that 32 million Americans could lose their insurance within a decade under a partial repeal of the ACA.
What has largely been missing from the debate is that repeal and replace will also affect the 150 million Americans who receive their healthcare insurance through their employer. The following improvements to employer-based insurance could be lost if the ACA is repealed, as a recent Health Affairs Blog post explains:
- Preventive services without cost sharing
- Pre-existing condition exclusions
- Dependent coverage until age 26 on their parents’ plans
- Annual out-of-pocket limits
- Prohibition of annual and lifetime limits
- External review when plans deny coverage
Another rarely discussed possible result of the repeal and replace strategy is the predicted loss of 2.9 million jobs in 2019 and 3 million jobs in 2021, as detailed by The Commonwealth Fund. About a third of the job losses will be within the healthcare industry, but two thirds will be in other sectors of the economy. Of interest, many of the states with the largest projected losses are states that voted for President-elect Donald Trump, who campaigned on a platform of job creation:
- Texas (175,000)
- Pennsylvania (137,000)
- Ohio (126, 000)
- Michigan (102,000)
- Florida (181,000)
Other effects of the repeal and replace effort by the Republicans may also surprise citizens who have not been paying close attention to the details of the ACA. Those include, according to Kaiser Health News:
- Loss of calorie counts at restaurants
- Loss of breast-feeding rooms in workplaces
- Loss of the ban on surprise bills from emergency department visits
- Elimination of hospital community health assessments
- Loss of women’s right see an OB/GYN without a primary care referral
- Elimination of autism therapy coverage
Reforming the American clinical delivery system is a complicated business that directly affects a fifth of the U.S. economy. Replacing the ACA with an alternative that does not create winners and losers will be a tricky business indeed.
Kent Bottles, M.D., is a lecturer at the Thomas Jefferson University School of Population Health and chief medical officer of PYA Analytics.