Do Not Repeal the ACA Without a Comparable Replacement

By | February 24, 2017

Barack Obama's signature on the Affordable Care ActI once saw a breast cancer so advanced that the tumor had eroded through the woman’s chest wall. This wasn’t in a foreign country with little access to healthcare – it was in the city where I attended medical school: New Haven, Connecticut. The patient worked a full-time job and raised a family, but did not have health insurance. She knew that seeking care for the lump she found in her breast would cost thousands of dollars even if it was nothing – so she ignored it. She didn’t seek care until she was crippled by pain and couldn’t breathe because her lung had filled with fluid from the tumor. She died soon after I met her. I will never forget her or her family, from whom she kept the tumor a secret. I hope I never see such a case again.

But I fear that I soon will. Donald Trump and the Republicans in the House appear poised to make good on their pledges to repeal the Affordable Care Act in the coming months. Repealing without replacement would double the number of uninsured people in the United States – from 29 million to 59 million individuals. Taking health insurance away from millions of Americans without a plan to offer them comparable alternative coverage is bad public policy and will cause untold suffering among innocent Americans who simply want access to care. It is the duty of our lawmakers to provide a reasonable alternative to the ACA if they repeal the law.

More than 80% of people who gained coverage through the ACA are in working families whose employers did not offer health insurance. If the ACA subsidies are repealed and the Medicaid expansion rolled back, these families would be left without access to affordable care. Similarly, the more than 1 in 4 adult Americans with pre-existing health problems, like cancer or diabetes, will never be able to afford commercial insurance again without the protections and subsidies provided by the ACA.

Some lawmakers have floated the idea of catastrophic coverage plans for ACA beneficiaries who cannot afford insurance without the subsidies. Others have called for rolling back important regulations, the 10 Essential Benefits of the ACA, that ensure that the insurance sold to consumers is comprehensive. While these changes could make insurance less expensive, those changes will mean less access to care. We know that patients with these plans will forgo necessary preventative care, like vaccines and mammograms. Catastrophic plans and plans with minimal coverage, with high deductibles and numerous restrictions, do not make healthcare more affordable overall, and do not keep people healthy.

In addition, repealing the ACA would introduce higher costs to the taxpayers, who must then compensate hospitals that care for critically ill, uninsured or under-insured individuals, like my former patient in New Haven all those years ago. The American Hospital Association estimates that those payments would balloon to almost $100 billion [PDF] in the years following the ACA repeal, and that hospitals will lose about $400 billion in revenue as people without insurance coverage can no longer afford care.

Most agree that the ACA alone was not enough to contain costs. Premiums are too high. Doctor and hospital networks are too small. Navigating the exchanges to purchase insurance is challenging. But simply repealing this legislation without any provision for those who will lose coverage is short-sighted and cruel. In the six years since the ACA was signed into law, 20 million people across the country have received insurance. During that time, approximately 1.5 million women have been diagnosed with breast cancer, and the ACA has provided coverage for tens of thousands of those women. Surely, one of those women is your sister, wife, friend, coworker, or neighbor. If Donald Trump and the Republicans in Congress succeed in repealing the ACA without a replacement, she could lose her health insurance in the middle of her chemotherapy or radiation next year.

I urge Congress to make sure that a comparable replacement is passed if the ACA is repealed. Make sure that pre-existing health problems and preventative care are still covered in a meaningful manner, and that patients are not bankrupted by a car accident or a tragic diagnosis. Make sure that no one has to choose between following up on a lump in her breast and financial devastation again.

Audrey Provenzano

Audrey Provenzano

Audrey M. Provenzano, MD, MPH is a General Internist in the Boston area. She cares for patients in a community health center and works in quality improvement. She is interested in primary care practice reform and quality improvement and healthcare policy. She is the host and producer of the primary care and health policy podcast Review of Systems, which can be found at
Audrey Provenzano

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