The American Health Care Act: What happened?

In the days since the Republican’s replacement plan for the Affordable Care Act (ACA), called the American Health Care Act (AHCA), failed to garner enough votes to make it through the United States Congress and was pulled from consideration, people have been asking why it failed. To Timothy Callaghan, PhD, a political scientist and assistant professor at the Texas A&M School of Public Health, that’s the wrong question. Instead, everyone should be asking why the bill was treated like it was likely to pass.

“This shouldn’t have been a surprise; it should have been the expected outcome,” Callaghan said. “If you look at the history of health reform in this country, going back over the last century, it’s a history of failure with only a few exceptions.” The largest of those exceptions occurred in 1965 with the passage of Medicare and Medicaid and, in 2010, with the ACA itself, which is also called ‘Obamacare.’

“Almost every U.S. president has made a major attempt at health reform,” Callaghan said, “but it’s much harder than you would expect to pass this kind of complicated and highly technical legislation.”

President Lyndon B. Johnson’s administration was able to pass Medicare, the health care coverage for Americans age 65 and over, and Medicaid, which does the same for people with disabilities and low income adults and their children. Although Medicaid was (and is) controversial, Medicare remains a fairly well-liked program. “Everyone seemed to think that elderly Americans should have access to care,” Callaghan said. “That remains a popular idea to this day.”

Perhaps reflecting those attitudes, Medicare was left largely intact under the ACA while Medicaid was expanded and reformed. Other provisions in the ACA, which was one of Former President Barack Obama’s top priorities when he took office, included an individual mandate for insurance coverage, subsidies for premiums and out-of-pocket expenses, prohibitions on annual and lifetime limits on how much coverage someone can receive and requirements that plans include certain “essential health benefits.”

“The ACA also includes two provisions that are almost universally supported: allowing children to stay on their parents’ plans until age 26 and making sure that insurance companies couldn’t deny coverage based on preexisting conditions,” Callaghan said. Those, along with other parts of the ACA, were maintained under the proposed American Health Care Act.

Other provisions of the ACA would have undergone dramatic change under the Republican replacement plan. For example, the individual mandate was to be repealed, but so were subsidies for out-of-pocket expenses. And although there were still to be some restrictions on the amount insurers could charge older Americans for coverage, that number was to be a maximum of five times more than younger people, instead of the ACA’s three times as much. “Some members of Congress thought that the updated measures looked too similar to the ACA and were too generous, while others thought the updated measures were too Draconian.”

It was essentially this divide that led to the failure of the AHCA. “There’s a civil war going on within the Republican party at the moment,” Callaghan said. “Because they couldn’t agree, nothing happened.”

Also, part of the problem might have been voter outrage. “With 24 million people losing coverage it was a tough sell,” Callaghan added.

Others may have been able to keep their insurance, but it would have been more expensive. “Many of the coverage provisions and the method of funding them and who would be eligible for benefits would have changed dramatically,” Callaghan said. Of course, the flip side of that would be that some people might have actually received greater tax credits.

Still, there are signs that the plan might not be completely dead. “When the failure happened, President Trump said he might decide to work with Democrats, who with moderate Republicans could make a big enough coalition to get something passed,” Callaghan said. “There is still some work going on behind the scenes, but it is no longer the top priority.”