Formerly IGSW News | VOLUME 24 | SPRING 2017

Issues and Views

Buckle up!

The Healthcare Reform Roller Coaster Is (Again) Leaving the Platform

By Robert Applebaum

Robert ApplebaumOne year during college, one of my housemates had car trouble, so I offered to help. In those days spark plugs and points were a common culprit, and while I had not ever actually done a tune-up, I had watched an experienced friend perform the task. Well, I quickly found out that taking an engine apart was quite a bit easier than putting the pieces back together. It appears that critics of the Affordable Care Act are now learning this same lesson.

As we look to repeal, replace, repair (or is it revise, reinvigorate, revamp?), we must first look back at the initial legislative debate over healthcare reform, in the early days of the Obama Administration and the One Hundred and Fifteenth Congress. These same issues are at the heart of today's stalemate—with the well-being of millions of Americans at stake.

What's the problem? From day one, there was fundamental disagreement about the problem that healthcare reform was supposed to solve. And as we all know, when we don't agree on the problem, it is pretty much impossible to agree on the solution. This was true in 2009 and it was true last month when the Republican Congress proposed and failed to pass their American Health Care Act.

In 2009, the reform group, led by President Obama, pointed to an existing U.S. healthcare system that was more expensive than those in other developed countries (many of which provide universal coverage), and yet did not produce high-quality outcomes and left more than 45 million Americans uninsured.

The counter view of the U.S. healthcare system, represented then and now by Republican Congressional leaders, was that the richest people in the world were coming to this country to get medical treatment, primarily because we have the best research, finest hospitals, best trained physicians, and best equipment and technology. If our system was costly, it was because of malpractice laws, a lack of competition, and a lack of individual responsibility.

The Affordable Care Act, the legislation that emerged and was passed on a party-line vote, offered solutions to the problems of limited coverage, high costs, and quality concerns, which were pretty much in direct conflict with the countervailing Republican perspective on system problems—not to mention solutions. In particular, efforts to expand coverage and to not allow insurers to deny coverage based on pre-existing conditions had been primary motivators for developing the ACA. To accomplish these goals, individual and employer mandates to purchase insurance and regulations disallowing insurers to deny coverage had to be critical components of the legislation. It was the individual and employer mandates that turned out to be the ideological lightening rod that galvanized opposition to the new law, quickly dubbed "Obamacare." Ironically, while the criticism of Obamacare has been loud from a segment of U.S. society, a recent survey found that one-third of respondents did not know that Obamacare and the Affordable Care Act were one and the same.

What next? Today, given the surprising failure of Congress to repeal the ACA and replace it with the American Health Care Act, the question remains. Twenty million Americans who did not have health insurance in 2009 are currently covered by the ACA. This and additional ACA benefits are becoming more widely recognized. The expanded coverage for children to age 26, the pre-existing conditions protections, and the closing of the Part D "donut hole" benefit for Medicare recipients are elements of the ACA that are widely supported, even among a majority of people who voted for Donald Trump. Even the controversial expansion of Medicaid has by and large been accepted. It was in part because of these developments, and with the 2018 Congressional election looming, that many moderate Republicans were not comfortable supporting the American Health Care Act, which would have rolled back coverage to millions of Medicaid recipients.

Now we wonder, is the Affordable Care Act "the law of the land for the foreseeable future," as House Speaker Paul Ryan declared when the AHCA went down? Or, was President Trump correct when he tweeted, only days later, "The Democrats will make a deal with me on healthcare as soon as ObamaCare folds - not long"? Buckle up!

Robert Applebaum, Ph.D., is professor of gerontology, Scripps Gerontology Center, Miami University, Oxford, Ohio.

Photo of Robert Applebaum courtesy Miami University

Back to Front Page

Copyright © 2017 Trustees of Boston University. All rights reserved. This article may not be duplicated or distributed in any form without written permission from the publisher: Center for Aging & Disability Education & Research, Boston University School of Social Work, 264 Bay State Road, Boston, MA 02215, U.S.A.; e-mail: