A week ago, Donald Trump told a crowd in the Philadelphia suburbs that “when we win on November 8 and elect a Republican Congress, we will be able to immediately repeal and replace Obamacare.” Today, with both a Trump presidency and a Republican congress inbound, the Affordable Care Act is in real danger. Just how Trump plans to follow through on a repeal process and what exactly will replace it is anyone’s guess. But a wholesale scrapping would take more away from Americans than they might realize.

People who want to repeal Obamacare tend to be angry about one thing: mandated coverage. The Medicaid expansion and private insurance exchanges outlined in Title I of the ACA have increased coverage by upwards of 20 million people, putting the nation’s uninsured rate at a historic low. Telling people they have to have insurance (especially if the rates they pay help subsidize people who are less well-off) is about as popular with conservatives as the EPA.

But healthcare exchanges and mandatory requirements only make up about a quarter of the ACA’s 955 pages. Buried in the rest are provisions that most people either don’t know about, or actually really like–from small business tax credits to extended dependent coverage to public health programs and rural patient protections. Here’s what a repeal will take off the table:

Birth Control

Obamacare entitles women in private plans access to all 18 FDA-approved birth control options–though some brand-name drugs and devices may only be covered with a co-pay. Right now, birth control costs approximately zero dollars for more than two-thirds of privately insured US women. Women on Medicaid are also covered under ACA, though the failure of at least 19 states to expand Medicaid left many thousands of women without this option. Since 2006, the unintended pregnancy rate has dropped by 6 percent, but remains high among poor minority women who are more likely to require public assistance. In 2010 unplanned births racked up a $21 billion Medicaid bill. Losing free access to birth control would have a significant financial impact on individuals and on the system. So get your IUDs now, while you still can!

The Prevention and Public Health Fund

One of the (really) lesser-known facets of Obamacare is this fund, the federal government’s largest single (and only) dedicated investment in disease prevention. Created by the ACA to improve public health and prevent chronic illnesses, the fund dedicates $14.5 billion over 10 years for programs that reduce people’s risks for things like cancer, diabetes, heart disease, and stroke–diseases that are responsible for seven out of every 10 deaths in America, and are largely preventable. The money goes directly to states for on-the-ground efforts to curb obesity, substance abuse, lead poisoning, and HIV, but it also goes to more large-scale initiatives.

When 1.6 million smokers attempted to quit smoking in 2012 because of the Center for Disease Control’s “Tips from Former Smokers” national ad campaign, that was the PPHF. In fact, more than half of the CDC’s chronic disease budget comes from the PPHF. These diseases represent one of the biggest drains on the health care system–$1.3 trillion in treatment costs and lost productivity every year. “The Prevention Fund is a critically important investment,” says Rick Hamburg, interim President and CEO of Trust for America’s Health, a public health non-profit. “Without it–well, I don’t even want to think about that.”

The Rule of 26

One of Obamacare’s most visible and non-partisan benefits has been allowing young people to stay on their parents’ health insurance plans until age 26. Sure, it hasn’t done much for millennials’ reputations as lazy, self-involved freeloaders, but this feature helped drop the rate of uninsured Americans aged 19 to 25 from 22.3 percent in 2010 to 18.4 percent in 2014. That’s 5.7 million young people gaining coverage in five years. Even Obamacare’s most stalwart antagonists see value in keeping this provision around for the long haul. In June, Republican lawmakers unveiled a proposal to replace the ACA that advocated continuing this provision.

Pre-existing Condition Discrimination

The Affordable Care Act won over some Republicans by telling insurers they could no longer deny coverage to people with pre-existing conditions. Considering that one in two Americans has a health condition that could qualify–asthma, diabetes, cancer, or pregnancy, to name a few–this is one aspect of Obamacare that would have a yuge impact were it to be repealed overnight. Some estimates put as many as 129 million Americans under the age of 65 at risk of being rejected for insurance without this provision of the ACA. Like the Rule of 26, it also made it into this summer’s Republican proposed Obamacare replacement.

Now, none of this is to say that the Affordable Care Act is perfect. It has some very real problems, like not meeting enrollment goals and rising premiums. Any new blood in the Oval Office offers a chance to look deeply and tease out what works and what doesn’t. But it’s also important to recognize that each provision doesn’t exist in a vacuum–they’re built on previous programs that have been around for many years. Untangling them, both pragmatically, and financially, is a tough task. Throwing it all out and just keeping what you like isn’t as simple as it sounds.

25 Comments

  1. Cart and horse issue. Need and labor are unrelated, I can grant you that. However, the purchasing of services and labor is directly related. Now, this labor may be supplied by the needy or some facsimile there of – friend, family, etc.

    As we continue down this trail we find another issue which surfaces – family. Classically, the family was constructed of multiple generations with an in built support system. Today, we have discarded such structures in search of hyper-individualism. But, that is a whole different rabbit to chase.

    So, let’s expand your premise. I have a need and no resources to resolve the need. I now levy upon you a fee so that I can acquire the resources to meet my need.

    Is that okay?

    Now, add to that, the fact that I live irresponsibly, consume large amounts of alcohol, drugs, etc.

    Still okay?

    And how about half of that fee not even going to my need, just to those “handling” the taking of your resources and giving them to me.

    Still okay?

    Or, how about we shrink government by 50% so that you keep the resources you earn and have savings to take care of yourself. For those less fortunate, we keep family circles together and create independent charities where 90% of the funds go where needed. We lower medical costs by removing the overhead and launching multiple small local clinics reserving hospitals for major surgery, procedures, and
    epidemics.

    Now that is better.

  2. “If I want the best healthcare, then I must labor for it.”
    This is the problem. The need for healthcare (ie how ill you get) is not related to how much labour you produce (how hard you work).
    If you’re healthy enough to work hard, and therefore earn enough to be able to buy good health care, then great, but if you’re too ill to work, then you can’t earn enough to get good health care and you’re basically screwed.
    I agree that the ACA is not fit for purpose, instead of mandating people have to buy insurance, just provide it for them. As you note, not having the overhead of multiple parallel care providers simplifies things and cuts costs.

  3. That freedom you describe is easily achievable – free markets. I would much rather see an open an competitive marketplace where I can select my services and pay accordingly. The difficulties you refer to come from the employers providing the benefit.

    Freedom is paired with responsibility. I am responsible for myself, and likewise you are responsible for yourself. If I want the best healthcare, then I must labor for it. It is wrong for you to consume services on someone else’s labor. If they wish to donate their labor to you, that is great. However, you cannot demand their labor for your convenience.

    The ACA does exactly that. It requires all to participate without their choice, fines them for non-compliance, and then provides services which the laborer disagrees with.

    Also, if we got rid of health insurance all together, medical costs would drop by almost 50%.

  4. “America’s historical freedom”, in this context that would be the freedom to be ill with no hope of treatment?
    Different from the freedom we have in other countries, which is the freedom to take any job without worrying about health insurance. That’s not a freedom you’d like?

    (For a moment I thought you were entitled to free bread, then I realised you meant bred)

  5. Because, I would rather not sacrifice America’s historical freedom, independence, and character. Our society has already emasculated men, bred entitlement, and debased itself. Now, we want to add more slavery?

  6. So, you are the first precious generation to have the “right” to live without pain? Wow… I guess I am not one of the “No one…” as I have a chronic illness, multiple injuries, and have gone years without medical care. And you know what? I am OK.

    “What kind of world is that?” Reality, child, reality.

    Work and reward go hand in hand. Generosity is a personal activity, not a governmental one. For the government to be generous, it must take from its populous. The more that government does, the more it must take.

  7. peterjohn936

    The Republicans won’t have a say.

  8. peterjohn936

    They do whatever it takes to generate more and more profit. That is what their executives get paid for.

  9. Geez. Is there any conservative anywhere in the world that knows how to read? He negotiated — badly. He paid FAR more than his properties were worth and that’s why he went bankrupt. Four times. He couldn’t maintain the cash flow necessary to finance all his bad deals.

  10. I’m sorry, the billions of $$ in properties that he has developed were all done by himself? He did not have to negotiate with anyone, especially in NY? Grow up, get real, accept reality.

  11. Politicalcrunch

    Really? You actually think the only thing that we don’t like
    about Obamacare is the Mandate? It is a big one, I’ll give you that! It
    gave us one of the worst and most destructive supreme court rulings in history
    of USA, up there with rulings allowing Japanese internment & Ruling that
    black people were property,

    Basically it sets precedent that we do not actually have any constitutional
    rights any longer, that is, they can pass any law regulating speech, forcing
    warrant less searches, no due process, etc…. you name it, as long as the
    enforcement mechanism is a tax penalty!

    How about my deductible going from $800 to $3,000 after year 1 of Obamacare and
    now up to $5,000 (not good for a guy who gets 2 CT Scans a year), my Company
    used to match what I put in HAS which helped but not any longer as premium
    increases ate that that up. I also ha
    a friend who has 2 kids who purchased through he exchange and her deductible,
    $10,000.

    Then there’s the fact that the # of full time jobs are fewer
    nowadays while most entry level work only offers part time hours (avoiding
    health insurance costs)

    If you like your plan you can keep it my B*&&! It
    will save families $2,500 a year!!!

    We can add to all this the fact that we know Obama and most Democrats
    want single payer, one size fits all system ( https://youtu.be/Kvg8qVKZYuM ).

    We need to go to a competitive system which allows
    competition across state lines, allows Insurance Companies to offer a wide variety
    of options for coverage, for instance, catastrophic high deductible policies
    for younger people who are not likely going to be visiting the doctor much and
    they can save some money in a tax free HSA to cover anything that does come up.
    Their policies would be cheap.

    We can solve the pre existing issue by maybe having Gov add
    a small tax ($15 month) and put in a
    fund which can cover these costs and only available to those not working and
    have been out of work no longer than 2 years.

    I hope that is enough, there is plenty more on this subject.

  12. There’s no point in arguing about it. To say he is not successful is to deny reality. In any case, he will be President Trump on January 20, so get used to it.

  13. No, it isn’t. Read the history I gave you again and tell me how he successfully negotiated with anyone except his daddy.

  14. No he’s not.

    My wife’s cousin is married to the former president of Novartis, Paolo Costa. HE is a respected business tycoon. He sits on the board of several multinational companies. And he will tell you point blank that nobody in New York will do business with Donald Trump. The reason is that he lies, he cheats, and he steals. He is an unreliable partner, an incompetent manager, and just way too big a risk for anyone to invest in.

  15. His “point” seems to be that Trump wouldn’t be a good negotiator or businessman, which is clearly at odds with decades of verifiable history.

  16. please stop. No one deserves to go through the ravages of something like cancer or even an infected tooth JUST because they can’t afford care. What type of world is that? It’s selfish and inhumane. You sound absolutely insane. Thoughts like this are why so many are nervous right now.

  17. you’re avoiding his ACTUAL point because you want big up Trump, can we just LISTEN to each other?

  18. The man is a respected and highly successful business tycoon. There’s no way around it.

  19. No, that’s owned by his corporation. I didn’t say he’s not rich. He inherited a LOT from his father. But if he’d just put it all in a stock index fund, he’d be richer today than he currently is. That’s a sign of how bad a businessman he is.

    Trump’s business career goes like this:

    1970s: The Era of Early Failures. Trump scored his first big success—the Grand Hyatt hotel in Manhattan—which relied entirely on loans personally guaranteed by Trump’s father. Fred Trump also arranged for Donald to obtain a personal line of credit of $35 million at Chase Manhattan:

    But Trump was unable to control his spending….In 1978, the same year that Fred Trump set up the credit line for his son at Chase Manhattan, Trump’s personal finances collapsed….Losses came across the board. A number of Trump’s New York rental properties—on Third Avenue, Fifth Avenue, East 56th Street, East 57th Street, East 61st Street and East 67th Street—all were financial flops….Partnership investments—Park Briar Associates, Regency Lexington Partners and 220 Prospect Street Company—contributed even more red ink. The interest owedto Chase Manhattan on Trump’s massive use of his credit line topped off the dismal financial performance.

    What I ride around in is irrelevant.

    ….No one could withstand these types of losses given the comparatively paltry amount of money available to offset them. So Trump took the same route he did for the rest of that decade and in decades to
    come: He borrowed more to keep himself afloat….On September 24, 1980,Fred Trump arranged for a series of loans totaling $7.5 million to his son….That same day, one of the Trump family’s companies, Trump Village Construction Corporation, lent Donald Trump an additional $976,238. All of the loans could be paid back at any time, and Donald Trump was not liable for any of the interest payments on them. That’s is powerful negotiation with his daddy.

    Early 1980s: The Era of Success. A chastened Trump apparently decides to buckle down and pay attention to work. It’s during this period that he puts together the parcels and financing for Trump Tower, one of his most successful projects. This is the briefest of the Trump eras.

    Mid 80s/early 90s: The Era of Catastrophic Failure.Trump reverts to form. He negotiates terrible deals for a USFL team, the Plaza Hotel, the Eastern Shuttle, and a yacht he never uses. He obsesses over plans to develop a grandiose project he called Television City, located on 57 acres of land along the Hudson River. But he bungles the deal and loses control. He builds casinos in Atlantic City, but epically mismanages them and loses a huge sum. By 1991 he’s broke. He avoids personal bankruptcy partly by browbeating his bankers and partly by pleading for tens of millions of dollars in loans from his father and his siblings.

    Mid/late 90s: The Era of Desolation. Trump finally emerges in 1995, no longer broke but no longer all that rich either. His marriage to Marla Maples is heading south, and ends in divorce in 1999. He keeps up a brave public face, but these are bleak years with nothing much to maintain his interest. Then, in 1999, Trump’s father dies, followed by his mother in 2000. Trump inherits roughly $70 million or so.

    2000 and beyond: The Era of Golf and Licensing. Building skyscrapers is now out of reach, since no one will lend Trump the kind of scratch that takes. So he starts overpaying for golf courses instead. Beyond that, he finally finds something he’s good at: making money from his mouth. He licenses his name to naive developers from overseas who still think he’s the king of real estate. He lends his name to a seemingly endless string of penny ante businesses—Trump steaks, Trump vodka, Trump radio—as well as a dodgy assortment of penny-ante scams—Trump University, Trump diets, Trump mortgages. In 2004, he hits
    the jackpot of random luck when reality king Mark Burnett chooses him to host The Apprentice, a show perfectly suited to Trump’s talents for bullying and bombast.

    So let’s see. One good negotiation for the properties to put together Trump Tower, apparently deciding that is too much work, followed by a life or powerful flim flam, not negotiations.

  20. I suspect that some states will try to keep an Obamacare alternative for themselves. Ideally, there would be a provision to prevent pre-existing condition discrimination. HOWEVER, how would we prevent citizens of other states from moving to the states disallowing pre-existing condtion discrimination as soon as they get an expensive disease? Insurance companies would go bankrupt or be forced to triple their rates when their pool is filled with cancer patients, etc. Just like gun control, state level control doesn’t work if you can’t stop something at the borders.

  21. Why not make it a right rather than a privilege?
    Plenty of other countries do, and have similar standards of healthcare, but for much less spent.
    http://www.commonwealthfund.or

  22. Stephen Miller

    I really appreciate your hopefulness, Wired. It’s as out of touch as your views on the role of technology in society, but I do appreciate it.

  23. I like it.

  24. Yet, since the ACA was introduced premiums have gone up, deductibles have skyrocketed, and options have constricted.

    Something BEAUTIFUL would be zero government involvement.

  25. 2Cents this is what terrifies me about Republicans taking control over government – the past 30 years the Right Wing Media has created a fictional view of the world. I did feel sorry for WingNuts when they said things “the government can work to identify cost drivers – law suits, fraud, etc. – and improve the situation.” like that is some magic pixie dust to solve the problems

    1. Obamacare HAS been working to identify cost drivers in medical system – that is why the healthcare cost increases curve has flatten out the past few years.
    2. Fraud see about
    3. law suit do not materially increase healthcare cost — the cost of healthcare itself is what materially increases healthcare cost.

    Trump said he was going to replace Obamacare with something BEAUTIFUL
    I can’t wait to see that!
    I have a feeling Republicans are going to repeal but not replace.

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