On a late March day in 2010, President Barack Obama signed the Affordable Care Act (ACA) into law. For many Americans, it was a day of celebration as they would finally be able to get the health care they needed at a price they could afford. For others it was a day of frustration and confusion, because even from the beginning it was apparent that this plan was not perfect. Over the past six years we have watched the success and failures of the bill as it was slowly put into action. In that time more than 20 million people have gained health insurance. Hundreds of patients with pre-existing conditions have been protected from losing their plans or being denied coverage. For the elderly, Medicare expansions have reduced the cost of prescriptions and allowed for more preventive services.
From the beginning, supporters of the ACA hoped it would be the solution to our not-so-perfect health care system. However, it hasn’t been an easy road for this law. When the online marketplaces began to roll out in 2013, thousands of Americans had trouble even accessing the website with glitches causing delays in processing. More recently there have been complaints about the upward trend in the cost of premiums and decreased competition and options in the marketplace. Even President Obama has pointed out the flaws of the ACA and its subsequent rollout, but a strong resistance to the law and its central tenets has been growing and it is difficult to ignore.
“Repeal and replace” has been the mantra of the Republican Party in regards to the future of health care during the entire election season. It was chanted at rallies, emphasized in the press, and one of the major points of President Donald Trump’s plan for his first 100 days in office. Now that the Republicans have successfully gained control of the executive and legislative branches of our government, the question of a repeal has shifted and we are stuck wondering what a replacement to the ACA could look like. There seem to be two major ideas proposed by the Republican Party, but, in my opinion, both lead to more questions than answers.
The first is the concept of health savings accounts and has been publicly supported by Trump himself several times in the past few months. It’s possible you have already heard of these, since about 20 million Americans currently have one. In case the concept is new to you, the idea is to set up a special account that you can place your own money into to be used to pay for various health care costs. For example, a patient can use their savings account to pay off a high co-pay at the dentist, or buy prescriptions, or pay the fee for the ambulance ride to the hospital when they were stricken with a heart attack. Whatever the need, you can dip into this account and use the money to cover the cost. A nice benefit that President Trump has pointed out is “these accounts would become part of the estate of the individual and could be passed on to heirs without fear of any death penalty.” The obvious downside of this option is the ability of individuals to contribute to a savings account probably relates to their ability to pay for health care in the first place. They aren’t concerned about passing on wealth to future generations. What they need is cheaper health care upfront, right now.
The second potential plan gives us a bit more insight into what the Republican Party thinks is an ideal health care bill. Paul Ryan released a 37-page report in June that outlined “a better way” for health care in America. So what does this better way look like? Well, it looks a lot like the ACA. Ryan makes sure that his plan still protects those with pre-existing conditions and gives tax cuts and subsidies to help pay for insurance. One major difference from our current system, however, is removing the mandate for individuals. In Paul Ryan’s future, a young, healthy adult who rarely goes to the doctor doesn’t need to get insurance if he or she doesn’t want it. Instead they can use the money they have saved from not paying an insurance premium and put it into their health savings account. It seems simple enough, but there is one big problem. The reason Obamacare works, in theory, is because the mandates ensure that healthy individuals buy into insurance just as much as those who are sick. This allows companies to spread their wealth around to those who actually need it the most, and keep costs down. The Republicans have pointed to the recent rise in premiums as proof that the mandate is not working, but if we take the mandates away, what is stopping costs from rising even more? They believe that the competition of free market will ensure that the health care system will continue to work. They are confident, but it feels like a risky venture to me.
We are already starting to see changes take place. Recently, Congress began the process of repealing the ACA. What is worrisome is that though they have every intention of repealing the ACA as soon as possible, they still haven’t started outlining a concrete replacement plan. This could leave thousands of Americans uncovered for years. As a future physician, this terrifies me. I began my path towards medicine well after the ACA was passed. My classmates and I entered medical school with the assumption that we would be practicing physicians in the world of Obamacare. Yet in recent weeks I have started to realize that the way I understood health care before medical school may be very different than the system I work in as a practicing physician.
Who knows what the next week, let alone the next four years, could look like with President Trump at the helm of our nation. However, there is one thing we can be sure of as the next generation of doctors: our future is different from the one we imagined at the start of our schooling. Toto, I don’t think we are in Kansas anymore.
Writer-in-Training
The Geisel School of Medicine at Dartmouth
I am a first year medical student at Dartmouth and currently loving the rural New England lifestyle that I signed up for. I graduated from the College of William and Mary in 2013 where I majored in neuroscience and minored in philosophy. I also have a Masters in philosophy of medicine from King's College London. My interests include bioethics, end of life care, and neuroscience. When I am not hitting the books I can be found running, sailing, re-reading Harry Potter, singing to Taylor Swift, or snapping pictures.