Dodging a Public Health Disaster, at Least for Now: What’s Next for Republican Plans to Repeal and Replace Obamacare?

Gerald F. Kominski

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After seven years of political assault, more than 60 votes in the House, two Supreme Court challenges, and repeated promises during the 2016 campaign season to repeal and replace the Affordable Care Act (ACA), Speaker Ryan had to pull his plan, known as the American Health Care Act (AHCA), last week because there just weren’t enough votes in the House for this alternative to Obamacare. From a pure public health perspective, this defeat means the nation has averted a significant disaster, the magnitude of which most Americans, including many who voted for the President and stand to lose their insurance, still don’t fully grasp. According to the Congressional Budget Office (CBO) analysis of the AHCA, 14 million people would have lost their health insurance by 2018, and 24 million by 2026, while reducing the federal deficit by merely $151 billion over ten years. Yet recent research suggests that mortality rates declined significantly after the implementation of the 2006 Massachusetts health reform law that served as the template for the ACA, as well as after pre-ACA Medicaid expansions. 1,2 Health insurance doesn’t just improve access to care, it saves lives. News reports showed many Obamacare recipients providing such testimonials to members of Congress during town halls leading up to the aborted vote on the AHCA.

The Speaker’s decision to pull the AHCA is a major political defeat for him, Republicans, and the President, but the war on the ACA is far from over. The Republican Party is fundamentally divided between the Freedom Caucus, which wants just to repeal the ACA without replacement, and moderate Tuesday Group Republicans, who believe that a replacement plan can’t move forward if it strips away eligibility solely to reduce the federal deficit. As we observed in the limited time between the release of the AHCA and its demise, adding more concessions to obtain Freedom Caucus support resulted in lost support among moderate Republicans. A major unanswered question is how and when do Republicans regroup to begin their new assault on the ACA, and how does the Speaker reconcile the diametrically opposed views of the conservative and moderate factions within his own party. The fundamental problem is that Republicans seem to have painted themselves into the proverbial corner by sticking with repeal and replace as a strategy. Unfortunately, this leaves a vacuum that I fear the White House will be all too willing to fill. The President has already claimed Obamacare is “exploding.” With a concerted effort by the White House and entire executive branch during the next few months, when insurers are deciding whether to participate in Exchange marketplaces and what their premiums will be, the 2018 open enrollment season at the end of this year could be disrupted just enough to create a self-fulfilling prophecy. This strategy – essentially, holding the ACA hostage – would be an attempt by the White House to force Democrats to the table and to agree to all sorts of concessions to preserve at least some core provisions of the ACA. Of course, the White House could also choose to reach out to Democrats, in a bi-partisan manner seeking genuine compromise, to craft a replacement bill that appealed to moderate Democrats, but that would require a level of political sophistication not yet demonstrated by this administration. They say politics isn’t for the fainthearted. But our politics have become so distorted that saving health insurance for 24 million people is now viewed as a major setback not just by the White House and many Republicans in Congress, but by millions of Americans. It’s hard to imagine how we cross that divide when we can’t even agree that we should be taking care of our fellow Americans.

About the Author

Gerald F. Kominski, PhD. is a professor at the Department of Health Policy and Management within the UCLA Fielding School of Public Health and director of UCLA Center for Health Policy Research.


  1. Sommers BD, Long SK, Baicker K. Changes in Mortality after Massachusetts Health Care Reform: A Quasi-experimental Study. Annals of Internal Medicine, 2014;160(9):585-593.
  2. Sommers BD, Baicker K, Epstein AM. Mortality and Access to Care among Adults after State Medicaid Expansions. NEJM, 2012;367:1025-1034.