The Defeat of Trumpcare

Since its launch in 1961, Transition has been a vibrant, international forum for the exchange of ideas and our Letters to the Editor section has featured many memorable responses and opinions. In this issue, a Mexican-American essayist reacts poetically to Donald Trump's promise to build a wall on the United States' southern border, and a renowned scholar of social security in Latin America reflects on recent efforts to repeal the U.S. Affordable Care Act. Letters and Opinions up to 1000 words in length can be sent submitted to transition@fas.harvard.edu for consideration, with the subject line Letter to the Editor.

Partly stirred by racism against the first African American President and seeking to kill his greatest domestic legacy, Trump pledged in the electoral campaign to repeal and replace Obama's Affordable Health Care Act (ACA), also known as Obamacare, as soon as he took office. He also vowed to provide "beautiful" health insurance to all Americans and to preserve Medicaid. Working in secret, without hearings, a group of all male, white senators elaborated various drafts to repeal (fully or partially) and replace Obamacare, though only 13% of Americans supported such plans. At the end of July 2017, all those drafts were defeated.

The World Health Organization ranked the U.S. health-care system 37^th among 191 countries—well below many other developed economies. This ranking is based on these key factors: 1.) extension of population coverage and inclusion of vulnerable groups including the poor, elderly, disabled, women, children and those with chronic illnesses; 2.) inequalities in provision that discriminate by age, gender, and health status;3.) government provision/regulation of care and fairness in its financing;4.) cost of services relative to GDP;5.) size of private and out-of-pocket health expenses; and 6.) output indicators such as life expectancy and infant mortality.

Based on the above-mentioned factors, this article shows that by maiming Obamacare, the House and Senate proposals (Trumpcare) exacerbate U.S. health-system problems.

Coverage and inclusion of vulnerable groups. Obamacare made health insurance coverage mandatory and facilitated access by expanding Medicaid to cover all adults with an income below 138% of the federal poverty level and by allowing individuals to purchase private insurance in the market. Jointly, these provisions incorporated 25 million formerly uninsured people, including low-income citizens, children, women, senior citizens, the disabled, and those with pre-existing conditions, many of whom had previously been denied health care insurance. Medicaid, a 52-year old program that helps 20% Americans, was expanded in 32 states. Large employers were required to offer health insurance to their employees or pay a fine, and both large and small businesses received tax credits. Significantly, Obamacare mandates that insurers can neither deny coverage nor raise premiums for pre-existing conditions.

According to the Congressional Budget Office, the Senate's first draft will take insurance away from 22 million people by 2026. Expanded Medicaid coverage by states will be phased out in four years, conveniently starting in electoral year 2020. This will leave 49 million Medicaid recipients under 65 uninsured. Insurance by big and small employers will sharply decrease because it will no longer be mandatory and fines will be eliminated. The repeal-only option will leave 32 million without insurance.

Inequalities. Obamacare set risk-pooling so that the young and healthy would pay proportionally more than the old and sick. Both the House and the Senate bills give insurers discretion to charge older consumers up to five times what they charge younger people.

Elimination of key guaranteed benefits. Obamacare guarantees ten new benefits, including preventive and maternity care, mental-illnesse and drug-addiction treatment, and prescription drugs. By permitting states authority to accept or waive key protections in the ACA, Trumpcare virtually dumps all ten of these benefits—thus letting insurers exclude certain individuals. Trumpcare also slashes funding for Medicaid, though the cuts proposed in the Senate are more extreme than those in the House bill. Additionally, Trumpcare defunds Planned Parenthood and nullifies tax credits for entities providing contraceptives and abortions. In 2016, the country experienced an opioid epidemic wherein 59...